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THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


GIFT 


Marion  D.  Harris 


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J^^^l^r^c^rt^uiU-^^       ty  /  JX/uyiyy^%y^iL <Q-Mi2^ 


THE    SCIENCE    AND   ART 


OF 


MIDAYIFEEY 


BY 

WILLIAM  THOMPSON  LUSK,  M.  D.,  LL.  D.  (Yale) 

PROFESSOR    OF    OBSTETRU'S    ANI)    THE    DISEASES    OF    WOMEN    AND    CHILDREN 

IN    THE    BELLEVTE    HOSPITAL    MEDICAL    COLLEGE 

CONSULTING    PHYSICIAN   TO   THE    MATERNITY    HOSPITAL   AND   TO   THE    FOUNDLING   ASYLtJM 

VISITING    PHYSICIAN    Tl  >    THE    EMERGENCY    HOSPITAL 

GYN.ECOLOGIST    TO    THE    BELLEVIE    AND    TO    THE    ST.    VINCENT    HOSPITALS 

HONORARY     FELLOW     OF     THE     EDINBURGH     AND    THE     LONDON     OBSTETRICAL     SOCIETIES 

CORRESPONDING    FELLOW    OF    THE    OBSTETRICAL    SOCIETIES    OF    PARIS    AND    LEIPSIC 

CORRESPONDING    FELLOW    OF    THE    PARIS    ACADEMY    OF    MEDICINE,    ETC. 


AEW  EDITION,   REVISED  AXD  ENLARGED 
WITH  NUMEROUS  ILLUSTRATIONS 


NEW    YORK 
D.    APPLETON    AND    COMPANY 

1899 


COPYRIGHT.  1881,  1885,  1892,  1P9C, 
By  D.   APPLETON  AND  COMPANY. 


Electrotvped  and  Printed 
at  the  appleton  press.  u.  s.  a. 


AUSTIN  FLINT,  M.D.,   LL.  D. 

IN   MEMORY   OF   MANY   YEARS   OF   FRIENDSHIP 

THIS    BOOK    IS    DEDICATED 

BY  THE  AUTHOR 


I  b  0 
L.'?75'£ 


PREFACE   TO   THE   FOURTH   EDITION. 


The  third  edition  of  this  work,  pubhshed  in  1885,  Avas  intended 
to  present  to  the  reader  a  picture  of  the  most  advanced  obstetrical 
teachings  of  that  date.  In  the  brief  interval,  liowever,  that  has 
elapsed  since  then  the  changes  that  have  taken  place  in  both  the 
theory  and  practice  of  obstetrics  have  made  it  necessary  for  me  to 
present  to  the  profession  what  is  essentially  a  new  book.  Thus 
many  modifications  in  the  theory  have  resulted  from  more  careful 
observations  in  anatomy  and  pathology,  and  from  fruitful  physio- 
logical investigations.  It  has  been  my  endeavor  to  interweave 
aseptic  precautions  with  all  branches  of  obstetric  art  without,  how- 
ever, insisting  upon  pedantic  measures  which  experience  has 
shown  to  be  needless.  But  the  noblest  conquests  of  the  past  years 
have  been  the  result  of  the  employment  of  modern  surgery  for  the 
relief  or  removal  of  a  host  of  complications  formerly  regarded  as 
beyond  the  pale  of  human  help. 

In  making  needed  alterations  I  have  not  felt  it  obligatoi-y  when 
new  discoveries  have  destroyed  the  value  of  former  deductions  to 
retain  these  in  order  to  maintain  a  reputation  for  consistency. 

I  thank  the  medical  press  and  the  medical  profession  of  this 
countr}^  and  Great  Britain  for  the  flattering  welcome  they  have 
hitherto  extended  to  this  treatise,  and  trust  that  in  its  new  form  it 
may  connnand  a  like  degree  of  favor. 

For  the  preparation  of  the  index  special  thanks  are  once  more 
due  to  my  friend  Dr.  W.  H.  Flint,  whose  painstaking  accuracy 
will  be  evident  to  those  who  have  occasion  to  consult  these  pages. 

April  13,  1892, 


CONTENTS. 


PHYSIOLOGICAL  ANATOMY. 
CHAPTER  I. 

PAGE 

Female  Organs  of  Generation  .  .  ,  .  ,      i 

The  pudendum.  —  Labia  niajora.  —  Clitoris.  —  Labia  minora. — Vestibule. — 
The  bulbs  of  the  vestibule. — Meatus  urethrje. — Sebaceous  glands. — Mu- 
cous glands. — Vaginal  orifice. — Hymen. — Vagina. — Vessels  of  vagina. — 
Uterus. — Fallopian  tubes. — Ovaries. — Vessels  of  uterus  and  its  append- 
ages.— Nerves  of  uterus. — Lymphatics. — Development  of  the  female  or- 
gans of  generation. — Arrests  of  development. 

PHYSIOLOGY  OF  THE  OVUM. 

CHAPTER  II. 
Development  of  the  Ovum        .  .  .  .  .  .35 

The  Graafian  follicles  and  the  ovum. — Discharge  of  the  ova  from  the  ovary, 
and  the  formation  of  the  corpus  luteum.^ — The  migration  of  the  ovum.— 
Fecundation. — Changes  taking  place  in  the  ovums  ubsequent  to  fecunda- 
tion.— Nourishment  of  the  embryo. — The  allantois  and  chorion. — The 
decidu^. — The  placenta  ;  its  development  and  structure. — Formation  of 
the  umbilical  cord. — The  amniotic  fluid. 

CHAPTER  III. 
Development  of  the  Fcetus      .  .  .  .  ,  .62 

Development  of  the  foetus  in  the  successive  months  of  pregnancy. — Fetal 
circulation. — Fcetus  at  term. — Fetal  ci'anium. — Attitude,  presentation 
and  position  of  foetus. 

PHYSIOLOGY  OF  PREGNANCY. 
CHAPTER  IV. 

Changes  Effected  in  the  Maternal  Organism  by  Pregnancy  .  77 
Changes  in  the  sexual  apparatus  and  neighboring  organs. — Changes  in  the 
uterus. — Explanation  of  apparent  shortening  of  cervix. — Changes  in  the 
vagina,  vulva,  abdomen,  navel,  breasts,  nipple. — Functional  disturbances 
of  bladder. — Constipation. — CICdema. — Changes  effected  in  the  entire  or- 
ganism. 

CHAPTER  V. 
The  Diagnosis  of  Pregnancy    .  .  .  .  .  .91 

Signs  of  pregnancy. — Suppression  of  menses. — Nausea. — Salivation. — Breasts. 
— Increase  of  abdomen. — Changes  of  the  os  and  cervix. — Quickening. — 
Ballottement. — Fetal  heart-beat. — Uterine  bruit. — Funic  souffle. — Inter- 
rogation of  the  patient. — Methods  of  physical  examination. — Inspection 
of  abdomen. — Palpation. — Auscultation. — The  vaginal  touch. — Distinc- 
tion between  first  and  subsequent  pregnancies. — Diagnosis  of  death  of 
foetus. — Duration  of  pregnancy. — Prediction  of  day  of  confinement  from 
date  of  last  mensti'uation. — Date  of  quickening. — Size  of  uterus. 


viii  CONTENTS. 

PREGNANCY. 

CHAPTER  VI.  p^g^ 

The  Management  op  Pregnancy  .  .  .  .  .112 

Hygiene  of  pregiiaiiey. — The  disorders  of  pregnancy. — The  blood-changes  of 
liregnatiey. — Pernicious  anaemia. — Hydneinic  oedema. — Varicose  veins. 
— Nausea  and  vomiting. — Keart-burn. — Insalivation. — Pruritus. — Face- 
ache. — Cephalalgia. — insomnia. 

LABOR. 

CHAPTER  Vn. 

The  Physiology  op  Labor  and  its  Clinical  Phenomena  .  .  123 

Causes  of  labor. — Uterine  contractions. — Action  of  labor-pains  upon  the 
uterine  walls. — Contraction  of  ligaments. — Action  of  abdominal  muscles. 
— Action  of  vagina. — The  pain  of  labor. — General  influence  of  labor- 
pains  upon  the  organism. — Precursory  symptoms  of  labor. — First,  second, 
and  third  stages  of  labor. — Duration. — Action  of  the  expellent  forces. 

CHAPTER  Vin. 

Mechanism  op  Labor       .  .  .  .  .  .  .140 

Anatomical  factors. — Anatomy  of  pelvis. — Sacrum.- — Coccyx. — Ossa  innomi- 
nata — The  ilia. — The  pubes. — The  ischia. — Articulations  of  the  pelvis. — 
Sacro-iliac  articulations. — Symphysis  pubis. — The  pelvic  ligaments. — Ob- 
turator membrane. — Sacro-sciatic  ligaments. — Inclination  of  the  pelvis. 
— The  pelvis  as  a  whole. — The  pelvic  planes. — Plane  of  the  brim. — Plane 
of  the  outlet. — Planes  of  the  cavity. — Ischial  planes. — Pelvic  axis. — 
Differences  between  male  and  female  pelvis. — Differences  between  the  in- 
fantile and  adult  pelvis. — The  soft  parts  of  the  pelvis. — The  perineal 
floor. — The  head  of  the  fa'tus  at  term.^Sutures  and  fontanelles. — The 
diameters  of  the  fetal  head. — The  articulation  of  the  head  with  the 
spinal  column. 

CHAPTER  IX. 

Mechanism  of  IuABOR.— {Continued.)     .  .  .  .  .168 

Presentations:  natural,  unnatural,  normal.— Vertex  presentations:  frequency, 
positions. — Manner  in  which  head  enters  pelvis. — Positions,  normal 
mechanism  of  labor. — Descent  and  flexion. — Rotation. — Extension. — Ex- 
ternal rotation. — Expulsion  of  the  trunk. — Abnormal  mechanism  (vertex 
presentations). — Mechanism  of  occipito-posterior  positions. — Configura- 
tion of  the  head  in  vertex  presentations. — Molding. — Scal])-tumor. — Di- 
agnosis of  vertex  presentations. 

CHAPTER  X. 

Mechanism  op  Labor— (Conifmned.)  .....  184 
Face  presentations. — Frequency. — Causes. — Mechanism. — Descent  and  exten- 
sion.— Rotation. — Flexion. — External  Rotation. — Abnormal  mechanism. 
— Configuration  of  head. — Diagnosis. — Prognosis. — Treatment. — Brow 
presentations.  —  Breech  presentations. — Causes.  —  Diagnosis. — Mechan- 
ism.— Irregular  mechanism. — Configuration. — Prognosis. — Treatment. 

CHAPTER  XI. 

Conduct  op  Normal  Labor        .  .  .  .  .  .205 

Preliminary  preparations. — Examination  of  the  patient. — Management  of 
the  first  stage. — Management  of  the  second  stage. — Preservation  of  the 
perina?um. — Delivery  of  the  shoulders. — Tying  the  cord. — Third  or  pla- 
cental stage. — Care  of  patient  after  delivery. — Treatment  of  perineal 
laeractions. — Amc-thetics  in  inidwiferv. 


CONTENTS. 


IX 


CHAPTER  XII. 

PAGE 

Multiple  Pregnancies  and  their  Management       .  .  .  228 

Frequency. — Origin. — Varieties. — Acardia. — Weight. — Unequal  development. 
Superfetation. — Diagnosis.  —  Labor. — Presentations. — Simultaneous  en- 
trance of  both  children  into  the  pelvis. — Locking. — Prognosis. — Conduct 
of  labor. 

THE  PUERPERAL   STATE. 

CHAPTER  XIII. 

The  Physiology  and  Management  of  Childbed      .  .  .  238 

The  puerperal  state  borders  closely  upon  pathological  conditions. — Post-par- 
tum  chill. — Temperature. — The  pulse. — General  functions. — Retention  of 
urine. — Loss  of  weight. — Involution. — Separation  of  the  decidua. — Clos- 
ure of  the  sinuses.— The  cervix. — The  vagina. — Position  of  uterus. 
After-pains. — The  lochia. — The  secretion  of  milk. — Anatomical  consider- 
ations.— Milk-fever. — Composition  of  milk. — Diagnosis  of  the  puerjieral 
state. — The  new-born  infant. — Changes  in  circulation. — The  navel. 
Tumor  upon  the  presenting  part. — Digestion. — Skin. — Icterus. — Loss  of 
weight. — Management  of  puerperal  state. — Sleep. — Passing  nrine. — 
Visits  of  physician. — Washing  the  vagina. — Diet. — Laxatives. — Nursing. 
— Duration  of  lying-in  period. — Care  of  new-born  infant. — Bath. — Cord. 
— Nursing. — Wet-nurses. — Artificial  feeding. 

THE  PATHOLOGY  OF  PREGNANCY. 
CHAPTER  XIV. 

Accidental  Complications. — Abnormities  of  the  Uterus.  .  260 

Variola.  — •  R-iiljeohi.  -7-  Scarlatina.  —  Scarlatina  puerperalis. — Cholera.  —  Ty- 
phus, typhoid,  and  relapsing  fever. — Malarial  fever. — Icterus. — Cai'diae 
diseases. — Pneumonia. — Emphysema,  chronic  pleurisy,  and  empyema. — 
Phthisis. — Syphilis. — Chorea. — Surgical  operations  during  pregnancy. — 
Double  uterus. — Anteversion  and  anteflexion. — Retroversion. — Retroflex- 
ion.— Prolapse  of  uterus  and  vagina. — Hernias. 

CHAPTER  XV. 
Diseases  of  the  Decidua. — Diseases  of  the  Ovum  .  .  .  284 

Endometritis  decidua:  I.  Chronica;  3.  Tubersoa ;  3.  Catarrhalis.— Anoma- 
lies of  the  placenta. — Anomalies  of  form  ;  of  position  ;  of  development; 
of  circulation.— Placentitis. — Degenerations. — Syphilis. — Anomalies  of 
the  amnion  and  of  the  amniotic  fluid. — Hydramnion. — Deficiency  of  am- 
niotic fluid. — Anomalies  of  the  umbilical  cord :  torsion;  knots;  liernias; 
coiling  of  the  cord  ;  cysts  ;  stenoses  of  vessels  ;  marginal  implantations. 
— Hydatidiforra  mole. 

CHAPTER  XVI. 
The  Premature  Expulsion  of  the  Ovum    .  .  .  .307 

Causes  of  abortion. — Disposition  to  abortion. — Immediate  causes. — Svmp- 
toms. — Moles. — Incomplete  abortions. — Diagnosis. — Prognosis. — Treat- 
ment.— Prophylaxis. — Arrest  of  threatened  abortion. — Treatment  of  in- 
evitable abortion. — Treatment  of  neglected  abortion. — Removal  of  fibri- 
nous polypi. — Treatment  of  miscarriage. 

CHAPTER  XVII. 
Extra-uterine  Pregnancy         ......  327 

Definition. — Tubal  pregnnncy. — Pregnancy  in  rudimentary  cornu. — Inter- 
stitial pregnancy. — Tubo-abdominal  and  tubo-ovarian  pregnancy.— 
Ovarian    pregnancy. — ALdominul    pregnancy.  —  Symptoms. — Termina- 


X  CONTENTS. 

PAGE 

tions. — Diagnosis. — Treatment  in  cases  of  early  gestation. — Cases  of  ad- 
vanced gestation  (foetus  living). — Cases  of  gestation  prolonged  after  the 
death  of  the  foetus. 

OBSTETRIC  SURGERY. 
CHAPTER  XVIII. 

The  Induction  of  Premature  Labor  .....  349 

Induction  of  premature  labor. — Indications. — Contracted  pelvis. — Habitual 
death  of  foetus. — Diseases  which  imperil  the  life  of  the  mother. — Opera- 
tion.— Catheterisatio  uteri. — Intra-uterine  injections.— Rupture  of  mem- 
branes.— Mechanical  dilatation  of  cervix. — Vaginal  douches. — Tampon. 
— Choice  of  methods. — Care  of  the  child. — Artificial  abortion. 

CHAPTER   XIX. 
Forceps        ,  .  .  .  .  .  .  .  .361 

History. — Vai'ieties  of  forceps;  short  forceps ;  long  forceps. — Action  of  for- 
ceps.— Indications. — Preparations. — Forceps  at  outlet.  — Operation  ;  in- 
troduction ;  locking ;  tractions ;  removal. — Forceps  at  brim  ;  operation. 
— Axis-traction  forceps. — Forceps  in  occipito-posterior  positions  ;  in  face 
presentations. 

CHAPTER  XX. 

Extraction  in  Foot  and  Breech  Presentations      .  .  .  382 

Extraction  in  pelvic  presentations. — Attitude  of  the  physician. — Prognosis. 
— Position. — Extraction  of  trunk.^Extraction  by  the  feet ;  by  the  breech. 
— Management   of    the   cord. — Liberation   of    "the    arms. — Exceptional 
cases. — Extraction  of  the  head. — Smellie's   method. — Veit's   method. 
Head  at  brim. — Prague  method. — Forceps  to  the  after-coming  head. 

CHAPTER  XXI. 
Version        .  .  .  .  .  .  .  .  .400 

Cephalic  version. — External  method. — Combined  method. — Busch. — D'Ou- 
trepont. — Wright. — Ilohl. —  Braxton  Hicks. —  Podalic  version. — Bipolar 
method. — Internal  version. — Neglected  version. — Use  of  the  fillet. 

CHAPTER  XXII. 
Craniotomy  and  Embryotomy    ......  413 

Craniotomy.— Indications. — Operation. — Perforators. — Method  of  perforating. 
— Extraction  after  perforation. — Forceps.— Cephalotribe. — Action  of  the 
cephalotribe.  —  Objections. — Application  of  the  cephalotribe.  —  Crani- 
oclast. — Crotchet  and  blunt  hook. — Cephalotomy. — Embryotomy. — Ex- 
enteration.— Decapitation. 

CHAPTER  XXIII 

Cesarean  Section.— Operations  of  Thomas  and  Porro    .  .  436 

CsBsarean  section. — History. — Indications.  —  Operation. — After-treatment. — 
Prognosis. — Operation  of  Porro. — Operation  of  Thomas. 

THE  PATHOLOGY  OF  LABOR. 
CHAPTER  XXIV. 

Anomalies  of  the  Expellent  Forces  .  .  .  .452 

Precipitate  labors. — Tardy  labors. — Irregular  pains  in  the  first  stage  of  labor. 
— Treatment  of  protracted  first  stage. — Irregular  pains  in  the  second  stage. 
— Treatment  of  protracted  second  stage. — On  the  use  of  ergot  in  labor. — 
Irregular  pains  in   the  third  stage ;   treatment. — Painful  labors :  from 


i 


CONTENTS.  xi 

PAQB 

hysteria;  from  rheumatism;  from  intestinal  irritation;  from  inflamma- 
tory changes. 

CHAPTER  XXV. 
Contracted  Pelves  .......  466 

Varieties. — Frequency. — Diagnosis. — Pelvic  measurements. — Forms  of  the 
contracted  pelvis. — Justo-rainor  pelves. — Flattened  non-rachitic  pelves. — 
Rachitic  flattened  pelves. — Generally  contracted,  flattened  pelves. — Ir- 
reg'jlar  forms.  —  Pseudo-osteomalacia.  —  Scoliosis.  —  Kyphosis. —  Influ- 
ence of  contracted  pelves  during  pregnancy  and  labor. — Influence  upon 
tlie  uterus. — Influence  upon  the  presentation. — Influence  upon  the  pains. 
— Influence  upon  the  first  stage  of  labor. — Influence  upon  the  mechan- 
ism of  labor. — Effects  of  pressure  upon  the  maternal  tissues. — Influence 
upon  the  fetal  head. — Effects  of  pressure  upon  the  integuments ;  upon 
the  cranium. — Prognosis. 

CHAPTER   XXVI. 

Treatment  of  Contracted  Pelves   .....  493 

Cases  of  extreme  pelvic  contraction,  rendering  delivery  per  vias  natnrales 
impossible. — Cases  indicating  craniotomy  or  premature  labor. — Cases 
where  extraction  of  a  living  child  at  term  is  possible. — Premature  labor. 
— Version. — Forceps. — Expectant  treatment. 

CHAPTER  XXVn. 
Rare  Forms  of  Pelvic  Distortion       .  .  .  .  .514 

The  Naegele  oblique  pelvis :  morbid  anatomy,  etiology,  diagnosis,  mechan- 
ism of  labor  in,  prognosis,  treatment. — The  kyphotic  pelvis  :  morbid 
anatomy,  etiology,  diagnosis,  prognosis. — Scolio-rachitic  pelvis:  anatomi- 
cal characters. — Robert's  pelvis:  anatomy,  etiology,  diagnosis,  prognosis. 
— Spondylolisthetic  pelvis :  anatomical  characters,  diagnosis,  prognosis. 
— Funnel-shaped  pelvis. — Osteomalacia. — Pelvis  narrowed  by  exostoses. 
— Divided  symphysis. 

CHAPTER  XXVIII. 
Abnormities  of  the  Sexual  Organs     .....  535 

Atresia  of  the  genital  canal. — Vulvar  atresia. — Vaginal  atresia. — Cystocele. — 
Rectocele. — Retention  of  urine. — Impacted  calculi. — Vaginal  hernias. — 
Cystic  degeneration  of  the  vaginal  wall. — Vaginismus. — Echinococci. — 
IJterine  atresia. — Conglutinatio  orificii  externi. — Cicatrical  atresia. — 
Rigidity. — Thrombus  of  the  cervix. — Symptoms  of  atresia. — Note  on 
treatment. — Tumors. — Fibroids. — Cancer.— Ovarian  tumors. 

CHAPTER   XXIX. 

Abnormities  of  the  Fcetus  which  Offer  an   Obstruction  to 

Delivery       ........  5.^1 

Premature  ossification  of  the  cranium. — Hydrocephalus. — Encephalocele. — 
Ilydrothorax. — Ascites. — Other  causes  of  abdominal  distention. — Tumors 
of  the  trunk. — Monstrosities. — Double  monsters. — Acardiaci. — Anen- 
cephalous  monsters. — Abnormal  positions.  —  Spontaneous  version. — 
Spontaneous  evolution. 

CHAPTER  XXX. 
Eclampsia    .  .  .  .  .  .  .  .  .567 

Definition. — Clinical  history. — Prognosis,  pathology,  and  etiology. — Treat- 
ment. 

CHAPTER  XXXI. 

Post-partum  hemorrhage  and  Retained  Placenta  .  .  581 

Normal  agencies  for  checking  haemorrhage. — Disturbances  of  contractility,  of 
retractility,  of  thrombus  formation. — Treatment. — Method  of  securing 


xii  CONTENTS. 

PAGE 

contraction  and  retraction. — Treatment  of  cerebral  anasmia. — Retained 
placenta. 

CHAPTER  XXXII. 

Placenta  Previa.— Accidental,  Hemorrhage.— Inversion  of  the 

Uterus  ........  594 

Situation. — Varieties. — Frequency. — Causes  of  hfemorrhage. — Clinical  feat- 
ures. —  Prognosis.  —  Diagnosis.  —  Treatment. —  Accidental  haemorrhage. — 
Inversion  of  the  uterus. 

CHAPTER  XXXIII. 

Ruptures  of  the  Genital  Canal         .....  610 

Rupture  of  tlie  uterus. — Etiology.— Pathological  anatomy. — Symptoms  and 
diagnosis. — Treatment. — Prophylaxis. — Treatment  after  ru{)ture. — Rupt- 
ure limited  to  the  peritoneal  covering  of  the  uterus. — Perforation  from 
pressure. — Lacerations  of  the  vaginal  portion. — Laceration  of  the  vagina. 
— Laceration  of  the  vulva. — Thrombus  of  the  vulva  and  vagina. — 
Rupture  of  the  pelvic  articulations. 

CHAPTER   XXXIV 

Prolapse  of  the  Funis,  etc.      .  .  .  .  .  .629 

Prolapsed  funis. — Asphyxia  neonatorum. — Collapse  and  sudden  death  during 
labor  and  childbed  from  thrombosis,  from  embolism,  and  from  entrance 
of  air  into  the  circulation. — On  the  extraction  of  the  child  in  case  of 
death  of  the  mother  in  pregnancy  or  labor. — Tympanites  uteri. 

DISEASES    OF   CHILDBED. 

CHAPTER  XXXV. 
Puerperal  Fever  .  .  .  .  .  .  .653 

Definition. — Frequency. — Morbid  anatomy. — Endometritis  and  endocolpitis. 
— Metritis  and  parametritis. — Pelvic  and  diffused  peritonitis. — Plilebitis 
and  phlebothrombosis.  —  Septicaemia.  —  Earlier  views  concerning  the 
nature  of  puerperal  fever. — The  nature  of  puerperal  fever  as  regarded 
from  the  standpoint  of  modern  investigation. — General  symptoms. — 
The  symptoms  of  endometritis  and  endocolpitis  ;  of  parametritis  and 
perimetritis;  of  general  peritonitis;  of  septicaemia  lymphatica;  of  se])- 
tica^mia  venosa ;  of  pure  septicajmia. 

CHAPTER   XXXVI. 

Puerperal  Fkykr.—  (Continued.)  .  .  .  .  .681 

Causes. — The  atmosphere. — Inoculation. — Season  of  the  year. — Social  state. 
— Relations  to  zymotic  diseases. — The  prevention  of  puerperal  fever. — 
Treatment. — Vaginal  and  uterine  injections. — Iodoform  bacilli ;  opium  ; 
leeches;  stapes;  laxatives;  quinine;  salicylate  of  sodium;  Warburg's 
tincture;  veratrum  viride;  digitalis;  antipyrine ;  alcohol ;  cold. — Treat- 
ment of  peritoneal  effusions  and  inflammatoi'v  exudations. 

CHAPTER  XXXVII. 

Puerperal  Insanity. — Phlegmasia  Alba  Dolens. — Diseases  of 

the  Breasts  .  .  .  .  .  .  .701 

The  insanity  of  pregnancy,  of  childbed,  of  lactation. — Phlegmasia  allja 
dolens. — Defective  milk  secretion. — Galactorrlioea. — Sore  nipples. — Sub- 
cutaneous inflammation  of  the  breast. — Submammary  abscess. — Paren- 
chymatous mastitis. — Galactocele. — Prophylaxis  of  ophthalmia  neona- 
torum. 

APPENDIX. 

Symphysiotomy      ........  713 


LIST   OF   ILLUSTRATIONS. 


FIOrRE  PAGE 

1.  The  external  parts  of  generation  (in  the  virgin).     (Sappey.) ....  2 

2.  Lateral  view  of  the  erectile  structures  of  the  external  organs  of  the  female 

(from  Kobelt),  two  thirds 3 

3.  Front  view  of  the  erectile  structures  of  the  external  organs  of  the  female 

(Kobelt.) 4 

4.  Vulva  of  a  woman  who  has  borne  children.     (Sappey.)          ....  6 

5.  Section  through  the  female  pelvis.     (Kohlrausch,  modified  by  Spiegeiberg.)  8 

6.  Complete  genital  organs  of  the  female.     (Beigel.) 11 

7.  Virgin  uterus.     (Sappey.) 12 

8.  Multiparous  uterus.     (Sappey.) 13 

9.  Virgin  uterus  opened  posteriorly.     (Bandl.) 14 

10.  Uterus  of  a  woman  who  has  borne  children.     (Bandl.) 15 

11.  Section  through  the  mucous  membrane  of  a  normal  virgin  uterus,  magni- 

fied about  forty  diameters.    (Kundrat  and  Engelmanu.)  .        .        .        .17 

12.  Section  through  uterus,  showing  cavity.     (Wel)er.) 18 

13.  Posterior  lateral  view  of  the  uterus,  with  portion  of  lig.  latum,  oviduct,  and 

ovary.     (Henle.) 20 

14.  Section  thi'ough  Fallopian  tube.     (Richard.) 20 

15.  Section  through  ampulla  (thirty  diameters).     (Luschka.)       .        .         .         .21 

16.  Longitudinal  section  of  ovary  from  a  person  aged  eighteen  (eight  diame- 

ters).    (Henle.) 22 

17.  Arterial  vessels  in  a  uterus  ten  days  after  delivery.     (Luschka.)   .        .        .24 

18.  Uterine  and  utcro-ovarian  veins  (plexus  pampiniformis).     (Sappey.)     .        .  25 

19.  Nerves  of  the  uterus.     (Frankenhaeuser.) 28 

20.  Rudimentary  sexual  organs.     (Luschka.) 29 

21.  Uterus  and  its  appendages  in  the  foetus  at  the  end  of  the  fourth  month  (nat- 

ural size).     (Courty.) 29 

22.  (Jterus  unicornis  from  a  young  child,  posterior  aspect.     (Pole.)    .         .         .30 

23.  Double  uterus  and  vagina  from  a  girl  aged  nineteen.     (Eiseumann.)    .        .  31 

24.  Uterus  oicornis,  double  cavity  and  double  vagina,  from  a  girl  seventeen 

years  of  age.     (Schroeder.) 32 

25.  Uterus  cordiformis,  double  natural  size.     (Kussmaul.) 33 

26.  Uterus  septus  bilocularis.     (Cruveilhier.) 33 

27.  Uterus  semi-partitus.     (Gravel.) 34 

28.  Section  of  Wolffian  body,  with  rudimentary  ovary  (embryo  of  chick,  fourth 

day  of  incubation).     (VValdeyer.) 35 

29.  Section  through  portion  of  the  ovary  of  mammal.     (Wiedersheim.)      .        .  36 

30.  Sagittal  section  of  the  ovary  of  an  adult  bitch  (after  Waldeyei').  .         .         .37 

31.  Spermatozoa  from  the  human  subject  (magnified  eight  hundred  diameters). 

(Luschka.) 43 


xjy  LIST  OF  ILLUSTRATIONS. 


FIGURE 


PACK 

32.  Ovum  of  the  nephelis  vulgaris,  showing  retraction  of  vitellus  and  the  pene- 
tration of  the  spermatozoa  through  the  vitelline  membrane  (magnified 

three  hundred  diameters).     (Robin.) 44 

38.  Fertilization  of  ovum  of  a  moUusk  (Elysia  viridis) 45 

34.  Formation  of  the  blastodermic  vesicle.     (Van  Beneden.)       .         .        .         .46 

35.  Diagrammatic  section  (Iladdon)  of  mammalian  blastoderm.        .        .        .  47 

36.  Surface  view  of  area  pellucida  of  hen's  egg,  after  eighteen  hours  of  incuba- 

tion.    (Balfour.) 47 

37.  Dorsal  view  of  embryonic  area  of  blastoderm  of  chick 48 

38.  Transverse  section  through  the  embryo  of  the  chick,  a  few  hours  after  the 

conmiencement  of  incubation 48 

39.  Diagram  representing  transverse  section  through  the  embryo  of  a  chick,  at 

the  end  of  the  first  day  of  incubation 48 

40.  Transverse  section  through  the  embryo  of  a  chick,  on  the  second  day  of  in- 

cubation (magnified  one  hundred  diameters).     .        .                          ,        .  49 

41.  Section  through  the  ovum  of  chick,  after  the  development  of  umbilical 

vesicle 49 

42.  Diagram  showing  early  stage  in  development  of  amnion 51 

43.  Diagram  showing  completion  of  the  amnion  and  formation  of  the  chorion  .  51 

44.  Human  embryo  at  the  third  week,  showing  villi  covering  the  entire  cho- 

rion.   (Haeckel.) , 52 

45.  Diagram  showing  the  exochorion ;  endochorion;  umbilical  vesicle ;  amnion 

and  pedicle  of  allantois 52 

46.  Diagram  showing  the  formation  of  the  decidua,  first  stage   .        .        .        .53 

47.  Diagram  showing  the  formation  of  the  decidua  completed    .        .        .        .54 

48.  Diagram  showing  the  branching  of  the  villi  and   the  connection  of  the 

larger  trunks  with  the  placenta 56 

49.  Diagram  oi  uterus  and  placenta  in  the  fifth  month 58 

50.  Diagram  of  the  umbilical  arteries  and  vein.     (Tarnier  and  Chantreuil.)       .  60 

51.  Human  germs  or  embryos  from  the  second  to  the  fifteenth  week  (natural 

size).     (Principally  after  Ecker.) 63 

52.  Diagram  of  the  fetal  circulation.     (Flint.) 67 

53.  Fetal  skull,  seen  from  the  side.     (J.  Veit.) 71 

54.  Fetal  skull,  seen  from  above.     (J.  Veit.) 71 

55.  Attitude  of  foetus  in  utero.     (Tarnier  and  Chantreuil.)        ....  73 

56.  Lower  segment  of  uterus,  sixth  month  of  pregnancy.     ^Hofmeier.)      .        .  79 

57.  Diagram  showing  apparent  shortening  of  cervical  cannl        .        .        .        .83 

58.  Uterus  from  a  multipara  who  died  in  the  last  montii  of  pregnancy,  showing 

cervix  of  normal  length,  with  membranes  adherent  to  the  os  internum. 

(Bellevue  Hospital.) 86 

59.  Diagram  for  computing  pregnancy.     (Schultze.) 109 

60.  Schultze  diagram 110 

61.  Diagram  showing  the  mucous  membrane  of  the  uterus 125 

62.  Diagram  showing  shape  of  uterus  during  a  7)ain.     (Lahs.)     ....  128 

63.  Diagram  showing  elevation  of  fundus  during  a  pain.     (Lahs.)      .         .        .  128 

64.  Diagram  showing  the  changes  in  the  thickness  of  the  uterine  walls  during 

labor.     (Lahs.) 129 

65.  Section  through  a  frozen  corpse.     Stage  of  expulsion.     (Braune.)        .        ,  132 

66.  The  uterus  and  parturient  canal.     Foetus  removed.     (Braune.)     .        .        .  133 

67.  Longitudinal  section  through  walls  of  uterus  in  eighth  month  of  pregnancy. 

(Bandl.) 137 

68.  Sacrum  and  coccyx  (anterior  surface.) 141 


LIST  OF  ILLUSTRATIONS. 


XV 


FIGURE  PAGE 

69.  Section  of  sacrum  and  coccyx 142 

70.  Os  innominatum,  before  consolidation 143 

71.  Outer  surface  of  os  innominatum 143 

72.  Inner  surface  of  OS  innominatum .         .         .  144 

73.  Section  through  the  left  sacro-iliac  articulation  (natural  size).     (Luschka.)  145 

74.  Section  of  symphysis.     (Luschka.) 14(5 

75.  Front  view  of  pelvis,  with  ligaments.     (Quain.) 146 

76.  Transverse  section  through  pelvis,  to  show  the  sacro-seiatic  ligaments. 

(Tarnier  and  C'hantreuil.)    .  147 

77.  Section  showing  the  inclination  of  the  pelvis  according  to  Naegele.     (Tar- 

nier and  Chantreuil.) 148 

78.  Diagram  showing  oscillatory  movements  of  sacrum.     (Duncan.)        .         .  149 

79.  Anterior  half  of  the  pelvis 149 

80.  Posterior  half  of  the  pelvis 150 

81.  Diameters  of  the  brim 151 

82.  Diameters  of  the  outlet 151 

83.  Section  showing  the  inclination  of  the  pelvis  according  to  Naegele.     (Tar- 

nier and  Chantreuil ) 152 

84.  Axis  represented  upon  a  vertical  section  through  a  plaster  cast  of  the  pel- 

vic cavity.     (Hodge.) 153 

85.  Vertical  section  of  a  female  infantile  pelvis.     (Fehling.)      ....  154 

86.  87.  Diagrammatic  representations  of  sections  through  the  infantile  and 

adult  pelves.      (Schroeder.) 155 

88.  Pelvis  covered  with  the  soft  parts,  with  removal  of  bladder,  uterus,  and 

rectum 157 

89.  Section  of  pelvis,  showing  the  pyriform   muscles.     (Tarnier  and  Chan- 

treuil.) .        .        .  • 158 

90.  Section  of  pelvis,  showing  the  internal  obturator  muscle.     (Tarnier  and 

Chantreuil.) 159 

91.  The  levator-ani  muscle,  as  seen  from  above.     (Dickinson.)  ....  160 

92.  The  levator,  seen  from  the  side,  when  the  ischium  is  removed.     (Redrawn 

from  Luschka  by  Dickinson.) 161 

93.  Antero-posterior  section  of  the  perineal  floor.     (Tarnier  and  Chantreuil.)  162 

94.  Muscles  of  the  perinaeum.     (Henle.) 163 

95.  The  parturient  canal.     (Hodge.) 164 

96.  Lateral  view  of  fetal  skull.     (Hodge.) 165 

97.  Fetal  head,  as  seen  from  above.     (Hodge.) 165 

98.  Antero-posterior  and  vertical  dia:neters  of  the  fetal  head.     (Tarnier  and 

Chantreuil.) 167 

99.  Vertex  presentation ;  child  surrounded  by  amniotic  fluid.     (Pinard.)         .  172 

100.  Figure  illustrating  the  mechanism  of  labor  in  occipito-anterior  deliveries. 

(After  Schultze.) 174 

101.  Attitude  of  fcetus.     (Tarnier  and  Chantreuil.) 176 

102.  Figure  illustrating  the  mechanism  of  labor  in  oecipito-posterior  positions. 

(After  Schultze.) 179 

103.  Outlines  showing  diflference  between  head  of  child  at  birth  and  four  days 

subsequent  to  delivery.     (Budin.) 180 

104.  Figure  showing  shape  of  head  in  oecipito-posterior  deliveries.     (Tarnier 

and  Chantreuil.) 181 

105.  Method  of  performing  external  palpation.     (Pinard.) 182 

106.  Attitude  of  head  in  face  presentations.     (Ribemont.) 186 

107.  Engagement  of  the  head  in  face  presentations.     (Tarnier  and  Chantreuil.)  187 


j^^j  LIST   OF  ILLUSTRATIONS. 


FIGURE 


PAGB 

108.  Mechanism  of  face  presentations.     (Schultze.) 188 

109.  Face  presentation,  chin  to  the  rear.     (Hodge.) 189 

110.  Outline  of  head  born  with  face  presenting 190 

111.  Same  head  five  days  later.     (Builin.) 190 

112-114.  Diagrams  showing  Schatz's  method  of  converting  face  presentations 

into  vertex  presentations 193 

115.  Outline  of  head  after  delivery,  the  brow  presenting.     (Budin.).        .        .194 

116.  Brow  presentation,  subsequently  converted  into  that  of  the  face.     (Mater- 

nity Hospital.) 195 

117.  Presentation  of  the  breech.     Left  dorso-anterior  position.     (Pinard.)        .  198 

118.  Showing  lateral  inflexion  of  the  trunk  during  delivery  of  the  breech.        .  200 

119.  Exit  of  head  in  breech  presentations.     Face  covered  by  perinjeum.     (Fara- 

boeuf  and  Varnier.) 201 

120.  Exit  of  head  in  breech  presentations 203 

121.  Showing  shape  of  head  in  breech  presentations.     (Budin.)  ....  203 

122.  Expression  of  the  placenta.     (Crede.) 220 

123.  Descent  of  the  placenta  according  to  Schultze 222 

124.  Showing  normal  descent  of  placenta.     (Duncan.) 223 

125.  Twin  placenta,  showing  arterial  anastomosis 229 

126.  Author's  case  of  acardia 230 

127.  Twin  pregnancy,  both  heads  presenting.     (Tarnier  and  Chantreuil.)        .  233 

128.  Twin  pregnancy,  head  and  breech  presenting.     (Tarnier  and  Chantreuil.)  235 

129.  Mammary  gland.     (Liegeois.) 246 

130.  Section  through  acinus  from  breast  of  a  nursing  woman.     (Billroth.)        .  248 

131.  Torsion  of  the  cord.     (Schauta.) 294 

132.  Knot  of  umbilical  cord.     (Leyman.) 295 

133.  Insertio  velamentosa.     (Lobstein.) 297 

134.  Specimen  from  hydatidiform  mole,  in  the  Wood  Museum  ....  299 
lb5.  Ovum,  with  imperfectly  developed  decidua;  outer  surface  of  vera.     (Dun- 
can.)       309 

136.  Uterus  with  basis  of  a  fibi'inous  polypus,  after  an  abortion.     (Frankel.)  314 

137.  Intraperitoneal  rupture  of  tube 329 

138.  Rupture  of  tube  between  the  folds  of  the  broad  ligament    ....  330 

139.  Pregnancy  in  rudimentary   cornu.     (Kiissmaul,  observed  by  Heyfelder.)  332 

140.  Interstitial  pregnancy.     (Hennig.) 333 

141.  Bifurcation  of  tubal  canal.     (Hennig.) 334 

142.  Crede's  apparatus  for  the  maintenance  of  the  body-heat  of  premature  and 

feeble  infants 357 

143.  Section  of  hospital  incubator.     (Tarnier.) 358 

144.  Forceps  of  Chamberlen 362 

145.  Forceps  of  Smellie 3fi2 

146.  Levret's  forceps 3(j3 

147.  Naegele's  forceps 364 

148.  Simpson's  forceps 365 

149.  Hodge's  forceps 365 

150.  Introduction  of  blades 37O 

151.  Blades  of  the  Tarnier  forceps  adjusted  to  the  sides  of  the  head  at  outlet. 

(Faraboeuf  and  Varnier.) 37I 

152.  IMethod  of  making  tractions 373 

153.  Position  of  operator  when  head  is  on  perinaeum 374 

154.  Forceps  applied  to  head  at  brim 375 

155.  Taylor's  narrow-bladed  forceps 376 


LIST   OF   ILLUSTRATIONS. 


xvii 


FIGURE  PAGE 

150.  Author's  modification  of  Tarnier's  forceps 378 

157.  Occipito-posterior  position.     Traction  in  a  downward  direction,  to  secure 

the  descent  of  the  head  beneath  the  pubic  arch.    (Farabceuf  and  Var- 
nier.) 380 

158.  Occipito-post«rior  position.     Elevation  of  handle  of  forceps,  to  aid  the  ro- 

tation of  the  occiput  over  the  perina'uin.     (Farabanif  and  Yarnier.)        .  380 

159.  Taylor's  method  in  mento-posterior  positions  of  the  face     ....  383 

160.  Method  of  seizing  the  breech 385 

161.  Method  of  seizing  both  extremities 387 

162.  Tarnier  forceps  applied  to  the  thighs.     (Ollivier.) 389 

163.  The  fillet,  in  dorso-anterior  position.     (Ollivier.) 390 

164.  The  fillet  in  dorso-posterior  position.     (Ollivier.) 391 

165.  Porte-fillet.     (Ollivier.) 393 

166.  Combined  traction  upon  mouth  and  shoulders.    (Farabceuf  and  Varnier.)  397 

167.  The  method  of  extraction  by  the  Prague  method 398 

168.  The  Prague  method  of  extracting  the  head 399 

169.  Chin  arrested  at  symphysis.     (Chailly-Honore.) 400 

170.  D'Outrepont's  method,  modified  by  Scanzoni 402 

171.  Version  in  head  presentations.     (Chailly-Honore.) 406 

172.  Version  in  dorso-anterior  position,  first  stage.     (Farabceuf  and  Varnier.)  408 

173.  Version  in  dorso-anterior  position,  second   stage.     (Farabceuf  and  Var- 

nier.)      409 

174.  Version  in  dorso-posterior  [tosition.     (FarabciMif  and  Varnier.)   .         .         .  410 

175.  Method  of  seizing  the  foot,  in  lireccli  cases.     (Farabceuf  and  Varnier.)        .  411 

176.  Braun's  repositor 412 

177.  Catheter  used  as  a  re])ositor 412 

178.  Scissors  of  Smellie 415 

179.  Simpson's  perforator 415 

180.  Blot's  perforator 415 

181.  Hodge's  craniotomy  scissors 415 

182.  Thomas's  perforator 416 

183.  Simpson's  basylist '    .  416 

184.  Trephine  perforator 416 

185.  Operation  for  perforating  the  child's  head 417 

186.  Cephalotribe  of  Blot 421 

187.  Cephalotribe  of  Scanzoni 421 

188.  The  author's  cephalotril)e 422 

189.  Simpson's  cranioclast 426 

190.  Braun's  cranioclast 427 

191.  Head  of  child  after  delivery  with  the  cranioclast.     (Simpson.)    .         .         .  427 

192.  ;Meigs's  craniotomy  forceps  (modified  by  Professor  I.  E.  Taylor.)         .         .  429 

193.  Crotchet ' 429 

194.  Dr.  Taylor's  right-angled  blunt  hook 430 

195.  Segment  removed  by  the  Tarnier  forceps-saw.     (P.  Thomas.)      .         .         .431 

196.  Braun's  decapitating  hook 432 

197.  Braun's  method  of  decapitation 433 

198.  Embryotome  of  P.  Thomas 434 

199.  Embryotome  adjusted  around  the  neck  of  the  child 435 

200.  Baudelocque's  pelvimeter 467 

201.  Schultze's  pelvimeter 468 

202.  Normal  inclination  of  the  symphysis  pubis.     (Spiegelberg.)        .         .         .  470 
20.3.  Diminution  of  angle  between  symphysis  and  pelvic  brim    ....  470 


LIST  OF  ILLUSTRATIONS. 
XVlll 

PAGK 
FIGURE  . 

204.  Increase  of  angle  between  symphysis  ami  pelvic  bnm 4<U 

205.  Specitnens  from  the  Wood  Museum  (Bellevue  Hospital).     No.  1,  Normal 

pelvis.     No.  2.  Justo-minor  pelvis 473 

206.  Flattened  rachitic  pelvis.     (Wood's  Museum.) 475 

207.  Small  symmetrical  I'achitic  pelvis.     (Wood's  Museum.)        .         .         .         .478 

208.  Pseudo-osteomalacia.     (Naegele.) 478 

209.  Scoliosis,     (Litzmann.) 479 

210.  Pressure-mark  upon  skull.     (Dohrn.) 490 

211.  Base  of  skull ^ •'•04 

212.  Method  of  applying  suprapubic  pressure.     (Munde.) G05 

213.  Naegele  oblique  pelvis.     (From  specimen  in  the  Wood  Museum.)       .         .  515 

214.  Specimen  of  kyphotic  pelvis.     (Litzmann.) 519 

215.  Specimen  of  scolio-rachitic  pelvis.     (Litzmann.) 522 

21G.  Kobert's  pelvis.     (Lambl.) 523 

217.  Spondylolisthetic  pelvis.     (Kilian.) 525 

•218.  Osteomalacia.     (Specimen  from  Wood's  Museum.) 530 

219.  Osseous  tumors  filling  pelvic  cavity.     (Naegele.) 533 

230.  Autiior's  case  of  acardia 558 

231.  Neglected  shoulder  presentation.     (Chiara.) 565 

222.  Birth  with  doubled  body.     (Kleinwachter.) 566 

233.  Diagram  showing  a  relaxed  and  a  contracted  uterus 583 

224.  Bimanual  compression  of  uterus.     (Breisky.) 586 

225.  Diagram  showing  unavoidable  placental  separation  as  a  consequence  of 

cervical  dilatation 597 

226.  Inversion  of  uterus 608 

237.  First  stage  of  replacement 609 

237a.  Second  stage  of  replacement 609 

228.  Diagram  showing  dangerous  thinning  of  lower  segment,  owing  to  the  non- 

descent  of  the  head  in  contracted  pelvis.     (Bandl.) 611 

229.  Case  of  ruptured  uterus 613 

230.  Retraction  in  a  case  of  shoulder  presentation.     (Bandl.)      ....  617 

231.  Robertson's  repositor 634 

232.  Specimens  of  micrococci 665 

233.  Diagram  showing  that  the  sacrum  forms  the  key  to  the  pelvic  arch. 

(Faraboeuf.) " 719 

234.  Ijateral  view  of  sacrum.     (Faraboeuf.) 720 

235.  Tiie  sacral  articular  surface.     (Faraboeuf.) ,  731 

236.  Diagram  showing  the  axis  of  rotation  for  the  ilium  after  symphysiotomy. 

(Faraboeuf.) 723 

237.  Illustration  showing  the  detachment  of  the  periosteum  from  the  ilium 

due  to  separation  of  the  pubip  bones.     (Faraboeuf.)         ....  733 

238.  Farabceuf's  method  of  fixing  the  ilium  to  the  sacrum 734 

239.  Diagram  showing  gain  to  pelvic  space  due  to  symphysiotomy.     (Fara- 

boeuf.)   ' 727 

240.  Frontal  section  through  symphysis  in  early  life.     (Faraboeuf.)    .         .         .  727 

241.  Transverse  section  thi'ough  symphysis  near  puberty.     (Faraboeuf.)    .        .   727 

242.  Transverse  and  sagittal  sections  through  symphysis  in  a  young  woman. 

(Faraboeuf.) 727 

243.  The  anterior  aspect  of  the  symphysis.     (Faraboeuf.) 728 

244.  Median  section  through  the  fibro-cartilaginous  plug  between  the  pubic 

bones.     (Faraboeuf.) 729 

245.  The  symphysis,  and  deep  portions  of  the  vulvar  region.     (Faraboeuf.)       .  730 


LIST  OF  ILLUSTRATIONS.  xix 

PIGITRE  PAOE 

24G.  The  vessels  upon  the  inner  surface  of  the  pubes.     (Faraboeui.)  ,         .        .  733 

247.  Anterior  surface  of  inflated  bladder.     (^Farabccuf.) 733 

248.  Veins  behind  the  synipiiysis  and  veins  of  the  bladder.     (Faraboeuf.)  .         .  784 

249.  Division  of  suspensory  lijjainent  of  clitoris.     (Faraboeuf.)   ....  737 

250.  The  pubic  arch  after  division  of  the  suspensory  ligauient.     (FarabcEuf.)    .  738 

251.  Incision  of  the  perichondrium  with  scalpel.     (Farabanit.)   ....  739 
253.  Extension  of  incision  with  scissors.     (Fai'aboeuf.) 739 

253.  Introduction  of  finger  and  grooved  guard  by  the  supra-pubic  route.   (F'ara- 

boeuf.) 740 

254.  Knife  of  Faraboeuf 740 

255.  The  grooved  guard  introduced  from  below  behind  the  pubis.    (Faraboeuf.)  741 
250.   Division  of  the  syinpiiysis.     (Faraboeuf.) 743 

257.  Introduction  of  sutures.     (Faraboeuf.) 744 

258.  Tying  the  sutures  while  the  bones  are  held  in  place  by  Faraboeuf's  fixation 

forceps 745 


PLATE  PACING  PAGE 

I.  Section  through  pelvic  organs  of  multipara,  ad  nafuram.    (Freund.) .        .      8 
II.  Fig.  1.  Deutoplasm-fonning  ovum  from  a  Graafian  follicle ^ 
of  a  woman  twenty-seven  years  old.  I 

Fig.  3.  Fresh  ovum  from  Graafian  follicle  of  a  woman  j  (^^S^^-f         •    ^^ 
thirty  years  old.  J 

III.  Fig.  1.  Human  embryo  at  the  ninth  week.     [  (Erdl )  .        .    53 
Fig.  3.  Human  embryo  at  the  twelfth  week.  J 

IV.  Microscopic  sections  in  puerperal  endometritis.     (Bumra.) ....  667 


THE 

SCIEiNCE  AND  ART  OF  MIDWIFERY. 


PHYSIOLOGICAL  AXATOMY. 


CHAPTER   I. 

FE3IALE  ORGANS   OF   OENERATION. 

The  pudendum. — Labia  majora. — Clitoris. — Labia  minora. — Vestibule. — The  bulbs 
of  the  vestibule. — Meatus  urethra). — Sebaceous  glands. — Mucous  glands. — 
Vaginal  orifice. — Hymen. — Vagina. — Vessels  of  vagina. — Uterus. — Fallopian 
tubes. — Ovaries. — Vessels  of  uterus  and  its  appendages. — Nerves  of  uterus. — 
Lymphatics. — Development  of  the  female  organs  of  generation. — Arrests  of 
development. 

The  female  organs  of  generation  may  be  properly  divided  as  fol- 
lows: 1.  The  external  parts,  or  pudendum,  and  the  vagina.  2.  The 
uterus,  Fallopian  tubes,  and  ovaries. 

The  external  parts  and  vagina  are  chiefly  concerned  in  the  act  of 
copulation.  As  they  likewise  constitute  the  channel  through  which 
the  child  passes  during  parturition,  a  knowledge  of  their  anatomical 
structure  becomes  of  importance  to  those  who  would  practice  the  ob- 
stetric branch  of  medicine. 

The  internal  organs,  i.  e.,  the  uterus.  Fallopian  tubes,  and  ovaries, 
assume  obstetrical  importance  in  connection  with  the  parts  they  play 
in  gestation.  Thus,  the  ovary  furnishes  the  germ  from  which  the 
new  being  is  developed.  The  Fallopian  tube  receives  the  germ,  and 
conveys  it  to  the  uterus.  In  the  uterus,  the  fecundated  germ  obtains 
the  nutritive  materials  necessary  for  its  subsequent  growth  and  devel- 
opment. 

1.  The  ExTERisTAL  Parts  of  GrE]s^EEATioN'  and  Vagina. 

The  Pudendum. — The  pudendum  comprises  all  those  parts  which 
are  perceptible  externally.  It  includes  the  mons  Veneris,  the  labia, 
the  clitoris,  the  nymphge,  and  the  hymen.     It  is  situated  at  the  lower 


PHYSIOLOGICAL   ANATOMY. 


opening  of  the  pelvis,  and  has  a  wedge-shape,  whence  the  term  cunmis, 
i.  e.,  cunens.  Its  base  is  formed  by  the  mons  Veneris,  a  fatty  cushion, 
abundantly  supplied  with  hair,  which  covers  the  symphysis  pubis.  As 
it  follows  the  curvature  of  the  lower  portion  of  the  trunk,  in  extreme 
inclination  of  the  pelvis  it  is  sometimes  directed  so  far  backward  as  to 
render  difficult  the  introduction  of  the  speculum  and  tlie  accomplish- 
ment of  tlie  sexual  act.     It  is  di- 


hf  4-^^ 


^.-  A- 


y^^ 


-i 


vided  in  the  median  line  by  the 
rima  piidendi,  which  extends  from 
the  mons  Veneris  to  the  peri- 
na^um.  Upon  each  side  of  the 
rima  there  are  two  longitudinal, 
slightly  curved,  and  rounded  folds 
of  integument,  which  rest  upon 
cushions  of  adipose  areolar  tissue. 
These  folds  constitute  the  so-called 
lahia  majora,  which,  like  the  mons 
Veneris,  are  covered,  though  to  a 
less  extent,  with  hair.  In  healthy 
young  women  they  are  firm  and 
full,  while  in  deteriorated  consti- 
tutions, and  in  advanced  life,  they 
become  wrinkled  and  jiendulous, 
from  diminution  of  the  adipose 
tissue. 

The  labia  majora  act  as  a  sort 
of  valve,  Avhich  closes  the  orifice 
of  the  vagina,  whence  the  term 
vulva  —  i.  e.,  valva,  the  folding- 
door  of  the  ancients.  When  the 
labia  are  full  and  well  rounded, 
they  are  approximated  closely  to- 
gether, and  form  the  vulva  coji- 
nivens.  With  the  loss  of  adipose 
tissue,  a  gaping  of  the  flaccid  labia 
ensues,  and  forms  the  vulva  Jiiaus. 
The  labia  offer  an  external  and  internal  surface.  The  outer  surface 
presents  the  usual  characteristics  of  tegumentary  tissue,  and  is  abun- 
dantly supplied  with  large  sebaceous  glands.  The  inner  surface  is  in 
all  respects  like  a  mucous  membrane,  except  that  it  possesses  seba- 
ceous glands  in  place  of  mucous  follicles.  The  subcutaneous  tissue 
is  composed  of  connective  tissue,  rich  in  elastic  elements,  and  con- 
taining fatty  lobules  continuous  with  the  underlying  adipose  structure. 
It  furnishes  support  to  an  abundant  venous  jilexus,  to  which  the 
turgescence  of  the  labia  in  pruritu,  and  under  sexual  excitement,  is 


Fig.  1.— The  external  parts  of  generation  (in 
the  virgin).  1,  labium  majus ;  2,  four- 
chette  ;  3,  the  nynipha  ;  4,  glans  clitoridis  ; 
5,  meatus  urethrae  ;  6,  vestibule  ;  7,  orifice 
of  vagina ;  8,  hynaen ;  9,  orifice  of  the 
glands  of  Duverney ;  10,  anal  orifice. 
(Sappey.) 


FKMALK   ORGANS   OF   (FENERATION. 


mainly  duo.  Tlu-  existence  of  contractile  elements  has  never  been 
demonstrated. 

The  two  extremities  of   the  vidva  have  been  designated,  res])ect- 
iveh',  the  (interior  and  2^of<terior  commiissures  of  the  labia ;  but  tliese 
terms,  so  far  as  they  convey  the  idea  of  connecting  bands  between  the 
labia,  are    incorrect,  for   Luschka* 
has  shown  that  the  labia  are  directly 
continnous  with  the   jnons  Veneris 
in  front  and  the  })erin(eum  behind. 

The  ditoris  is  a  small,  elongated 
body,  situated  beneath  the  so-called 
anterior  commissnre.  It  resembles 
the  i^enis  in  form  and  structure,  but 
differs  in  possessing  neither  corpus 
spongiosum  nor  urethra.  The  cli- 
toris is  divided  into  the  crura,  the 
corpus,  and  the  glans.  The  crura 
are  long,  spindle-shaped  processes, 
attached  to  the  borders  of  the  as- 
cending rami  of  the  ischia  and  the 
descending  rami  of  the  pubis.  The 
corpus  is  formed  by  the  junction  of 
tlie  crura  in  the  median  line,  just 
beneath  the  pubic  arch.  Even  in  a 
state  of  extreme  erection,  it  does  not 
normally  exceed  an  inch  in  length. 
The  glans  is  the  rounded,  imper- 
forate extremity.     During  erection 

it  attains  the  dimensions  of  a  small  pea.  The  cuticular  covering  of 
the  glans  is  of  a  pale-red  color,  and  is  covered  with  papillae,  part  of 
which  contain  vessels,  and  part,  nerA-e-endings  similar  to  those  found 
in  the  nipple,  and  termed  by  Krause  "terminal  bulbs"  [End-Kolhen). 
The  nerves  of  the  clitoris  are  more  fully  develoi^ed  than  the  cor- 
responding nerves  in  the  penis.  The  clitoris  is  regarded  as  the  seat 
of  the  voluptuous  sensations  experienced  by  the  female  during  copu- 
lation. 

The  labia^  minora  are  twoiuirrow,  reddish,  moist  folds  of  mucous 
membrane,  situated  between  the  labia  majora,  Avith  which  they  are 
continuous  by  their  outer  surface.  The  inner  surface  is  continuous 
Avith  the  mucous  membrane  of  the  vestibulum.  The\'  are,  sometimes, 
termed  likewise  the  nyniphm.  XymphcB  vocantur  vd  quod  sint  casti- 
tatis  prmsides,  vd  (juod  xponsum,  prima  internLittant,  vd  quod  aquis 
prosilientihus  prcBsint  (P]azzonus),f  or,  as  Sir  Charles  Bell  words  it 

*  LcscHKA,  Die  Anatoinie  des  menschliclieii  Beckens,  p.  407. 
f  Und.,  Tiibingen,  18G4,  p.  408. 


Fir:.  •,'.  Lateral  view  of  tlie  erectile  struct- 
ures of  the  external  organs  of  the  fe- 
male (from  Kobelt),  two  thirds.  The 
l)loo(l-vessels  have  i)eeii  injected, ,  and 
the  skin  and  mucous  membrane  have 
been  removed,  n,  bulbus  vestibuli  ;  c, 
Iilexiis  of  veins,  named  the  pars  inter- 
media ;  e,  glans  clitoridis ;  /,  corpus 
clitoridis  ;  h,  ilorsal  vein  ;  I,  right  crus 
clitoridis  ;  j/i,  v'estil)ulum  ;  »i,  rightgland 
of  Barthohn  or  Duvernev. 


4  PHYSIOLOGICAL  ANATOMY. 

in  his  Anatomy,  "  The  most  modest  of  the  uses  ascribed  to  them  is 
that  of  directing  the  stream  of  urine."  Wlien  the  rima  pudendi  is 
narrow,  as  in  virgins,  the  labia  minora  are  concealed  and  protected  by 
the  labia  majora.  In  the  vulva  hians,  the  labia  minora  acquire,  from 
exposure  to  the  atmosphere,  a  dirty-bluish  color,  and  take  on  the  prop- 
erties of  the  cutis.  In  Hottentot  and  Bushman  women,  they  some- 
times reach  the  length  of  eight  inches,  and  constitute  the  so-called 
"  Hottentot  apron." 

Each  labium  minus  splits  anteriorly  into  two  folds,  of  which  the 
outer  joins  the  corresponding  one  of  the  opposite  side  to  form  a  cover 
for  the  clitoris,  the  prcBinitimn  clitor'idis.  The  lower  folds  converge 
to  meet  beneath  the  lower  border  of  the  glans  clitoridis,  and  form  the 
frenuluDi  of  the  clitoris.  This  attachment  serves  to  bring  the  clitoris 
forward  into  contact  with  the  penis,  as  the  labia  minora  are  pressed 
inward  during  copulation. 

The  labia  minora  meet  posteriorly,  in  most  instances,  and  form  a 
thin  circular  band,  the  frenulnm  vulvce  ox  fourchette.  The  fourchette 
has  usually  been  regarded  as  the  posterior  commissure  of  the  labia 
majora ;  but  this  view  Luschka  has  shown  to  be  incorrect.* 


V  .^^^ 


/!i% 


Fig.  3.— Front  view  of  the  erectile  structures  of  the  external  organs  of  the  female  iKolielf^ 
A  pubis  ;  B,  B  ischium  :  C,  clitoris  ;  D,  gland  of  the  chtoris  ;  E.  bulb  :  F,  constrictor  muscle 
of  the  vulva ;  G,  left  pillar  of  the  clitoris  :  H,  dorsal  vein  of  the  clitoris  ;  I.  intern  edarv 
plexus  ;  J,  vein  of  communication  with  the  obturator  vein  ;  K,  obturator  vein  •  JI  labia 
minora.  '      '  "'^"* 

The  vestihulum  is  the  angular  space  bounded  by  the  labia  minora 
and  the  vaginal  orifice. 

The  hulhi  vestihuU  vagince,  the  bulbs  of  the  vaginal  estibule,  are 
two  curved,  leech-shaped  masses  of  reticulated  veins,  situated  between 
*  Luschka,  Die  Anatomie  des  menschlichen  Beckens,  Tubingen,  1864,  p.  404, 


FEMALE  ORGANS  OF  GENERATION.  5 

the  vestibulum  and  pubic  arch  of  each  side.  Kobelt  has  shown  that 
they  correspond  to  the  two  separated  halves  of  the  male  bulbus  ure- 
thra. They  are  composed  of  erectile  tissue,  and  measure,  when  dis- 
tended with  blood,  a  little  over  an  inch  in  length.  As  the  head  of  the 
child  passes  through  the  vulva  during  parturition,  these  bodies  are 
2)ressed  forward  to  prevent  their  being  compressed  between  the  head 
and  the  pubic  arch.  Still,  rupture  does  sometimes  occur,  and  then 
the  haemorrhage  leads  to  the  formation  of  thrombus  of  the  labia  ma- 
jora.  The  upper  ends  of  the  vaginal  bulbs  are  rather  pointed,  and 
communicate,  by  means  of  a  small  plexus,  the  pars  intermedia  of 
Kobelt,  with  the  vessels  of  the  glans  clitoridis.  Through  this  connec- 
tion the  blood  is  pressed,  during  venereal  excitement,  by  the  reflex 
contractions  of  the  musculus  constrictor  cunni,  from  the  turgid  bulbs 
into  the  glans  of  the  clitoris. 

The  meatus  uretlircB  is  situated  in  the  median  line,  at  the  lower 
portion  of  the  vestibular  space,  about  three  quarters., of  an  inch  from 
the  glans  of  the  clitpris.  It  is  surrounded  by  a  ring  of  muscular  fibers, 
which  keep  it  closed  under  ordinary  circumstances.  These  fibers  cause 
a  puckering  of  the  mucous  membrane,  which  is  easily  recognized  by 
the  experienced  finger,  and  serves  as  a  guide  for  the  introduction  of 
the  catheter. 

Sebaceous  glands  are  found  in  great  abundance  in  the  tissues  of 
the  nymphffi,  where '  tlK'y  furnish  a  fatty,  yellowish-white  material, 
possessing  a  peculiar  odor.  This  material,  when  accumulated  beneath 
the  prepuce  of  the  clitoris,  constitutes  the  smegma  prmputii,  so  com- 
mon in  women  who  neglect  the  niceties  of  the  toilet. 

The  mucous  glands  of  the  vulva  are  divided  into  the  glandulfe 
vestibulares  majores  and  the  glandule  vestibulares  minores. 
.,  The  glandidce  vestibulares  minores  are  from  five  to  seven  in  num- 
ber, and  are  irregularly  distributed  in  the  neighborhood  of  the  meatus 
urethra?.  They  are  of  the  compound  racemose  variety,  of  about  the 
size  of  poppy-seed,  and  j)ossess  short,  wide  ducts  with  large  orifices. 
T\'ler  Smith  says  that  one  of  these  lacunae  may  be  enlarged  suffi- 
ciently to  admit  a  small-sized  catheter,  leading  the  operator  to  suppose 
that  he  has  reached  the  bladder,  while  the  instrument  is  really  in  a 
cul-de-sac* 

Professor  Skene,f  of  Brooklyn,  has  drawn  attention  to  the  exist- 
ence of  two  glandular  structures,  from  three  eighths  to  three  quarters 
of  an  inch  in  length,  situated  in  the  muscular  walls  of  the  urethra. 
The  orifices  of  these  glands  are  found  about  an  eighth  of  an  inch 
above  (within)  the  outer  border  of  the  meatus.  The  correctness  of 
this  observation  I  have  had  frequent  opportunity  to  verify. 

*  W.  TvLER  Smith.  Manual  of  Obstetrics,  p.  22. 

t  Skene,  The  Anatomy  and  Physiology  of  Two  Important  Glands  of  the  Female 
Urethra,  American  Journal  of  Obstetrics,  April,  1880.  p.  265. 


r, 


PHYSIOLOGICAL  ANATOMY. 


The  ylanthdiB  vesiihulares  majores  were  first  discovered  iu  the 
human  subject  bv  Bartlioliu,  and  bear  sometimes  his  name  and  some- 
times that  of  Duvernev.  They  are  two  in  number,  of  the  size  of  a 
pea,  and  of  a  reddish-vellow  color.  They  are  situated  behind  the  pos- 
terior extremities  of  the  bulbi  vestibuli,  which,  however,  they  partially 
overlap.  They  are  of  the  compound  racemose  variety,  and  their  acini 
open  into  a  duct  a  little  over  a  half-inch  in  length,  wide  at  its  begin- 
ning, but  which  narrows  toward  its  orifice.  The  duct  takes  an  oblique 
course  along  the  inner  side  of  the  vaginal  bulbs,  and  terminates  m 
front  of  the^hymen,  at  the  angle  whicli  the  hymen  or  its  remains  (the 

carunculai  myrtiformes)  makes 
with  the  Avails  of  the  vestibule. 
The  glands  of  Bartliolin  secrete 
a  yellowish,  adhesive  fluid,  which 
is  poured  out  freely  during  coit- 
us, and  preparatory  to  the  pas- 
sage of  the  child  at  the  time  of 
labor.  This  secretion,  by  render- 
ing the  parts  moist  and  slippery, 
serves  to  protect  the  mucous 
surfaces  from  mechanical  injury. 
An  abundant  secretion  may  like- 
wise be  caused  by  erotic  dreams, 
or,  in  fact,  by  any  form  of  sexual 
excitement.  They  are  more  de- 
veloped in  young  persons  than 
in  those  of  middle  life,  and  in 
old  age  they  seem  in  some  cases 
to  disappear  altogether. 

The  urifichim  rar/incp  differs 
greatly,  both  as  to  size  and  ap- 
pearance, in  virgins,  in  women 
accustomed  to  sexual  intercourse, 
and  in  those  who  have  borne 
children. 

In  virgins  {vide  Fig.  1)  the 

anterior  extremity  of  the  vagina 

terminates  in  a  thin  membranf , 

termed  the  hymen,  which  pio- 

jects  between  tlie  labia  minora. 

The  mucous  membrane  of   the 

inner   surface  of  the  hymen   is 

continuous  with  that  of  the  vagina ;   the  outer  surface  is  covered  by 

an  extension  of  the  mucous  covering  of  the  vulva.     The  space  between 

the  two  mucous  surfaces  contains  blood-ve.ssels,  connective  tissue,  and 


'ii^fl; 


Fig.  4.— Vulva  of  a  ^\ ninan  wlio  has  borue  chil- 
dren. 1,  labium  uiajus  ;  2,  fourehette  ;  3.  la- 
bium minus;  4.  interior  layei- passing  beneath 
the  clitoris  ;  5,  upper  laj-er  forming  the  pre- 
puce ;  6,  clitoris  ;  7,  prepuce  ;  8,  meatus  ure- 
thra ;  9,  vestibule  ;  10.  oriflce  of  the  vagiua, 
showing  lower  portion  of  the  vaginal  canal ; 
11,  orifice  of  the  gland  of  Duverney  ;  13,  mons 
Veneris.    (Sappey.) 


FEMALE  OKGANS  OF  GENERATION.  7 

a  few  muscular  fibers  derived  from  tlie  vaginal  walls.*  The  vaginal 
orifice,  which  is  therefore  in  virgins  identical  with  that  of  the  hymen, 
has  usually  a  crescentic  shape,  with  its  concave  border  looking  toward 
the  urethral  orifice,  so  that  a  small  opening  is  left  anteriorly  for  the 
escape  of  the  menstrual  fluid.  There  are,  however,  a  number  of  other 
less  common  varieties,  of  which  the  following  are  the  most  important : 
1.  The  hymen  annularis,  with  a  small  central  opening.  2.  The  hymen 
cribriformis,  with  a  number  of  small  openings.  3.  The  hymen  imper- 
foratus, which  completely  occludes  the  vagina,  and  occasions  retention 
of  the  menses.  4.  The  hymen  fijnbriatus,  from  its  resemblance  to  the 
fringed  extremity  of  a  Fallopian  tubei  Tliis  variety  possesses  medico- 
legal importance,  from  the  possibility  of  its  being  mistaken  for  a  nor- 
mal ruptured  hymen. 

The  thin  tissues  which  constitute  the  hymen  are  usually  lacerated 
by  the  first  complete  coitus.  Laceration,  however,  is  not,  in  all  eases, 
the  necessary  result  of  sexual  intercourse.  A  young  girl,  nineteen 
years  of  age,  at  one  time  under  treatment  for  amenorrhcea  in  the  uter- 
ine wards  of  the  Bellevue  Hospital,  i)ossessed  a  perfect  hymen,  the 
opening  of  which  was  of  the  ordinary  size,  yet  so  distensible  was  its 
tissue  that  a  medium-sized  (one  inch)  Fergusson  speculum  was  repeat- 
edly introduced,  for  purposes  of  exploration,  without  in  the  slightest 
degree  affecting  its  integrity.  Hyrtl  mentions  a  specimen  of  the 
female  genitalia  preserved  in  ^leckel's  museum,  at  Halle,  where  the 
hymen  is  perfect,  though  the  woman  had  given  birth  to  a  seven- 
months  child,  f 

We  are  indebted  to  Schroeder  for  having  pointed  out  that  the 
fleshy  eminences,  known  as  the  carunculffi  myrtiformes,  are  the  result 
of  child-bearing,  and  not,  in  the  rule  at  least,  of  sexual  intercourse. 
Coitus  simply  causes  a  solution  in  the  continuity,  at  one  or  more 
points,  of  the  free  border  of  the  hymen.  The  pressure  of  the  child's 
head,  however,  during  labor  causes  necrosis  and  sloughing  of  the 
heretofore  persistent  though  lacerated  hymen,  of  which,  subsecpiently, 
the  familiar,  isolated  elevations  of  mucous  tissue  about  the  vaginal 
orifice  furnish  the  only  visible  traces. J  My  own  experience  is  entirely 
confirmatory  upon  this  point.  In  the  examination  of  young  nulliixx- 
rous  prostitutes,  who  enter  the  Bellevue  Hospital  for  uterine  disor- 
ders, I  have  always  found  a  torn  hymen,  but,  in  no  case,  caruncula? 
myrtiformes. 

AVith  the  destruction  of  tli«  hymen  the  orificiiim  vaginm  is  bounded 
by  the  labia  minora  and  the  vestibule. 

*  Vide  BuDix.  Recherches  sur  Thymen  et  I'orifice  vaginale.  Publication  du 
progres  raedicale,  1879. 

t  Hyrtl,  Handbuch  der  topographischen  Anatomie,  Wien,  5te  Auflage,  Bd.  ii, 
p.  162. 

X  Schroeder,  Schwangerschaft,  Geburt,  und  Wochenbett,  Bonn,  1867,  p.  6. 


8 


PHYSIOLOGICAL  ANATOMY. 


The  Vagina.— Tlie  vagina  is  a  membranous  canal,  connecting  the 
nterus  with  the  external  parts  of  generation.  It  runs  in  an  oblique 
direction  forward  from  its  attachment  at  the  cervix  to  its  orifice  at  the 
vulva  When  not  artificially  dilated,  its  anterior  and  posterior  walls 
are  in  contact  with  each  other.  The  length  of  the  vagina,  owing  to  its 
extraordinary  distensibility,  is  usually  greatly  over-estimated.     Admit- 


Fig.  5. — Section  through  the  female  pelvis  (diagrammatic).  1,  rectum  ;  2,  uterus  ;  3,  excavatio 
recto-uterina  (eul-cle-sac  of  Douglas) ;  4,  excavatio  vesico-uterina  ;  a,  bladder ;  6,  clitoris  ; 
7,  urethra  ;  8,  symphysis  ;  9,  sphincter  ani  ;  10,  vagina  ;  11.  connective-tissue  layer.  (Kohl- 
rausch  modifleil  by  Spiegelberg.) 

ting  considerable  variations,  dependent  upon  weight,  position,  etc.,  of 
the  uterus,  two  and  a  half  inches  for  the  anterior,  and  a  little  over 
three  inches  for  the  posterior  Avail  may  be  accepted  as  fair  average 
measurements.*  The  vagina  is  placed  between  the  rectum  and  blad- 
der, and  is  more  or  less  intimately  connected  with  both  those  organs. 
In  its  upper  fifth,  the  vagina  is  separated  from  the  rectum  by  the  cul- 

*  LuscHKA,  Die  Anatoraie  des  menschlichen  Beckens,  Tiibingen,  1864,  p.  383. 


PLATE  I, 


Section  through  pelvic  organs  of  multipara,  ad  naturam.  (Freund.)  1,  Uterus  ;  2,  vagina; 
3,  bladder  :  4.  excavatio  recto-uterina  ;  5,  excavatio-vesico-uterina ;  6,  fornix  vaginae  ; 
r,  external  os  ;  8,  internal  os  ;  9,  uterine  cavity,  with  raucous  lining  ;  10,  septum  urethro- 
vaginale. 


FEMALE  ORGANS  OF  GENERATION.  9 

de-S(w  of  Dougliis.  From  thence  downward,  the  rectum  and  vao-ina 
form  a  common  partition,  the  !<ejjtuni  recio-vaginule.  Above  the  pel- 
vic floor  a  layer  of  connective  tissue  continuous  with  the  pelvic  fascia 
unites  the  rectum  and  vagina  together.  Below  the  pelvic  floor  the 
union  of  the  two  organs  is  immediate.  Luschka  limits  the  term 
"  septum  recto-vaginale  "  to  this  lower  half  of  the  common  wall.* 

The  upper  half  of  tiie  anterior  vaginal  wall  is  attached  to  the  blad- 
der by  means  of  loose  connective  tissue,  while  the  lower  half  is  insepa- 
rable from  the  tissues  about  the  urethra.  The  partition  thus  formed 
between  the  urethra  and  vagina  is  termed  the  .septum  urethro-vaginale. 

The  for7iix,  as  the  upper  part  of  the  vagina  is  termed,  encircles  the 
vaginal  portion  of  the  cervix  in  such  a  way  as  to  extend  at  least  twice 
as  liigh  upon  its  jiosterior  as  upon  its  anterior  aspect.  The  vaginal 
walls,  when  not  distended  artificially,  are  directly  applied  to  the  vaginal 
portion  of  the  cervix. 

The  structure  of  the  vaginal  walls  is  not  identical  in  all  parts  of 
the  canal.  In  the  upper  portion  the  internal  surface  is  nearly  smooth, 
and  the  walls  measure  from  a  half  a  line  to  a  line  in  thickness.  They 
are  composed  of  a  mucous  membrane,  a  muscular  coat,  and  an  external 
connective-tissue  sheath,  or  layer.  The  latter  is  highly  elastic,  and 
aft'ords  support  to  the  vaginal  blood-vessels.  The  muscular  fibers,  Avhich 
are  of  the  invpluntary  variety,  run  in  both  a  longitudinal  and  trans- 
verse direction,  and  are  so  interwoven  together  that  a  dissection  into 
distinct  strata  is  imjiossible. 

The  connective-tissue  and  muscular  layers  gradually  increase  in 
thickness  as  they  approach  the  vaginal  orifice.  A  circular  bundle  of 
voluntary  fibers,  the  sphincter  vagi  nee  of  Luschka,  surrounds  the  lower 
extremity  of  the  vagina  and  urethra.  The  contraction  of  this  sphincter 
not  only  acts  upon  the  vaginal  orifice,  but  likewise  serves  to  close  the 
urethra  by  compressing  it  against  the  septum  urethro-vaginale.f 
/'  The  vaginal  columns  are  two  thickened  ridges,  which  occur  in  the 
median  line,  upon  the  anterior  and  posterior  walls,  at  the  lower  jDortion 
of  the  vagina.  The  anterior  column  is  more  prominent,  in  the  rule, 
than  the  posterior.  It  is  often  divided  into  two  portions  by  a  longi- 
tudinal furrow.  In  these  thickened  ridges  the  muscular'  fibers  possess 
a  trabecular  arrangement  and  inclose  offshoots  from  the  venous  plexus. 
The  columns  thus  present  a  cavernous  structure.  They  are  not,  how- 
ever, endowed  with  erectility.  When  turgid  with  blood,  they  serve 
to  close  the  vagina,  but  the  resistance  they  offer,  like  that  afforded  by 
a  filled  sponge,  is  easily  overcome.  J  The  mucous  membrane  covering 
the  columns  is  greatly  thickened,  and  abundantly  supplied  with  vessels. 

*  Luschka,  Die  Anatomie  des  menschliehen  Beckens,  Tiibingen,  1864,  p.  384. 
t  Ibid.,  p.  387. 

j  Hexle,  Handbuch  der  Eingeweidelehre  des  Menschen,  Braunschweig,  1866, 
p.  450. 


^^  PHYSIOLOGICAL  ANATOMY. 

The  vao-ina  is  likewise  furnislied  with  transverse  ridges  (cristce,  not 
-^ruQ^-thev  are  not  wrinkles),  which  are  more  fully  developed  upon 
the  anterior  than  upon  the  posterior  wall.  In  virgins  these  ridges 
possess  a  nearlv  cartilaginous  consistence.  Any  relaxing  agency,  sucli 
US  chronic  cat"arrh,  child-bearing,  and  the  like,  serves  to  efface  them, 
and  render  the  vagina  smooth. 

y  The  mucous  membrane  of  the  vagina  is  covered  with  numerous. 
Kascular  papilh^,  which,  under  certain  conditions,  especially  those  per- 
taining to  pregnancy,  may  reach  such  a  degree  of  development  as  to 
communicate  to  the  finger  a  distinctly  granular  sensation. 

Though  the  secreting  glands  of  the  vagina  *  are  few  in  number,  it 
is  covered,  even  in  periods  of  repose,  with  a  thin  layer  of  acid  mucus. 
Under  sexual  excitement,  and  during  menstruation  or  pregnancy,  the 
amount  of  this  secretion  is  largely  increased. 

The  hypogastric,  the  uterine,  the  vesical,  and  the  pudendal  arteries 
nil  send  branches  to  the  vagina.  The  pulsations  of  the  uterine  artery 
may  sometimes  be  felt  through  the  upper  part  of  the  vaginal  walls. 
During  pregnancy  these  pulsations  are  always  so  distinctly  marked  as 
to  constitute  a  good  inferential  sign  of  that  condition. 

The  veins  form  a  close  plexus  around  the  vagina.  Like  all  the 
pelvic  veins,  they  are  without  valves,  and  are  therefore  peculiarly  sub- 
ject to  stasis  from  anything  that  interferes  with  the  return  circulation. 
Blood-stasis,  with  enlargement  of  the  vaginal  veins,  communicates  a 
deep-purple  color  to  the  vagina.  As  the  requisite  conditions  are  ful- 
filled during  gestation,  Jacquemin  and  Kluge  include  this  coloration  of 
the  vagina,  which  they  compared  to  wine-lees,  among- the  signs  of  preg- 
nancy. It  occurs,  however,  though  perhaps  to  a  less  intense  degree,  in 
prolapsus  uteri,  in  cases  of  pelvic  tumors,  and  the  like.  As  free  inter- 
communication exists  between  the  vaginal  plexus  and  the  plexuses  dis- 
tributed to  the  pudendum,  the  rectum,  the  bladder,  and  the  uterus,  a 
disturbance  in  the  circulation  of  any  one  of  these  organs  is  necessarily 
attended  with  some  degree  of  circulatory  disturbance  in  all  the  con- 
tiguous organs. 

The  general  relations  of  the  external  and  internal  organs  of  genera- 
tion are  admirably  given  in  Fig.  6,  Avhich  we  have  borrowed  from 
Beigel.f  It  represents  the  complete  generative  system  of  a  virgin 
(natural  size). 

II.  The  Uterus,  Fallopian  Tubes,  and  Ovaries. 

The  Uterus. — The  uterus  in  the  virgin  differs  somewhat  in  shape 
and  size  from  that  of  a  woman  who  has  borne  children.     The  follow- 

*  The  occasional  presence  of  glands  in  the  vagina  has  been  demonstrated  by 
Preiischen.     Vide  Virchow's  Archiv,  1877,  vol.  Ixx.  p.  111. 

\  Beigel,  Die  Krankheiten  des  weiblichen  Geschlechtes,  Erlangen,  1874.  Bd.  i, 
p.  23,  Pig.  2. 


FEMALE  ORGANS  OF  GENERATION. 


11 


12 


PHYSIOLOGICAL   ANATOMY, 


ing  description  is  intended  to  apply  to  the  nulliparous  uterus  only :  In 
outward  form  the  uterus  has  been  compared  to  an  inverted,  wide- 
necked  flask.  It  is  flattened  antero-posteriorly.  Its  average  length  is 
in  the  neighborhood  of  two  and  a  half  inches,  though  its  dimensions 
vary  to  a  verv  considerable  extent.     It  is  divided  by  a  tolerably  well- 


V...  I .  -  \  irg-in  utt-ius.  A.  amen  n  \  n  «  I  nuciiiii  -Neitioii  (\  lati  i  »1  st'itioii  ihapjjev  ; 
A,  1,  body  ;  2,  2,  angles  :  3,  oei  \  i\  1  site  of  tlie  os  iiit<  i  nnm  ,  "),  \<i}riticil  poi  tioii  of  the  cer- 
vix ;  6,  external  os  ;  7,  7,  vagina  B  1,  1,  piofile  ot  the  anteiior  stii  face  2,  vesico  uterine 
.  cul-de-sac  ;  3,  3,  profile  of  the  posterior  Siufaue  ,  4,  body  .  5,  neck  ,  6.  istlmius  ,  'i,  ^avity  of 
the  body  ;  8,  cavity  of  the  cervix  ;  9,  os  internum  :  10.  anterior  Up  of  the  os  externum  ;  11. 
posterior  lip  ;  12,  12,  vagina.  C,  1,  cavity  of  the  botly  ;  2,  lateral  wall  ;  3,  superior  wall  ; 
4.  4,  cornna  ;  5,  os  internum  :  6.  cavity  of  the  cervix  ;  7,  arbor  vitae  of  the  cervix  :  8,  os  ex- 
ternum ;  9,  9,  vagina. 

defined  constriction  into  two  parts  of  nearly  equal  length.  The  upper, 
larger  portion  possesses  an  anterior,  flattened,  and  a  posterior,  convex 
surface.  It  is  limited  by  three  borders  The  upper  border  is  moder- 
ately convex.  The  lateral  borders  are  convex  above  and  concave  below. 
The  Fallopian  tubes  pass  into  the  uterus  at  the  junction  of  the  upper 
and  lateral  borders.  The  width  of  the  uterus  at  this  point  is  about  one 
inch  and  a  half.  The  lower  portion  has  a  spindle  shape,  and  measures 
about  a  half-inch  in  its  widest  diameter. 

All  the  lower,  spindle-shaped  portion  of  the  uterus  is  termed  the 
cervix,  or  neck.  The  portion  of  the  uterus  comprised  between  the 
neck  and  the  Fallopian  tubes  is  called  the  coi'pus,  or  body.  The  seg- 
ment situated  above  the  Fallopian  tubes  is  distinguished  as  t\ve  fundus. 

The  lower  extremity  of  the  cervix  projects  freely  into  the  vagina, 
and  forms  the  portio  vaginalis,  the  vaginal  portion.  It  possesses  a 
transverse  aperture,  measuring  from  a  half  a  line  to  two  lines  in  width, 
termed  the  external  orifice,  or  sometimes  the  os  tincm,  from  a  fancy  of 
the  anatomists  that  it  resembled  the  mouth  of  a  tench.  The  external 
orifice  is  bounded  by  two  thick  lips,  of  which  the  anterior  is  absolutely 


FEMALE  ORGANS  OF  GENERATION. 


13 


longer  than  tlie  posterior.  As,  however,  the  distuuce  from  the  external 
orifice  to  the  vaginal  insertion  is  about  half  as  great  anteriorly  as  pos- 
teriorly, a  sensation  is  communicated  to  the  finger,  when  an  examina- 
tion is  made  j>ey  vaginam,  as  though  the  anterior  lip  were  really  the 
shorter  of  the  two.  This  absolute  superior  length  of  the  anterior  lip, 
combined  with  the  natural  oblique  direction  of  the  uterus,  causes  the 
external  orifice  to  look  nearly  directly  backward,  a  fact  which  is  readily 
recognized  when  the  organs  are  examined  in  situ  by  means  of  a  Sims's 
.■speculum. 

Upon  lateral  section,  the  uterus  is  found  to  be  provided  with  a 
cavity,  in  which  the  upper  portion  or  cavity  of  the  body  is  to  be  dis- 
tinguished from  the  lower  portion  or  canal  of  the  cervix.  The  cavity 
of  fJte  body  presents  a  triangular  shape  with  convex  borders.  The  two 
upper  angles  communicate  by  a  small  opening,  hardly  large  enough  to 
admit  a  fine  bristle,  with  the  canal  of  the  Fallopian  tubes.  At  the 
lower  angle  is  situated  the  os  internum,  a  circular  orifice,  large  enough 
to  admit  a  uterine  sound,  which  forms  the  internal  anatomical  limit 
between  the  body  and  the  cervix.  The  canal  of  the  cervix  has  a  fusi- 
form slia])e,  and  is  included  between  the  internal  and  external  orifices 
ah-eady  described.  Its  inner  surface  is  characterized  by  two  longitu- 
dinal ridges,  occupying  the  anterior  and  posterior  walls,  from  which 


Fig.  8.— a,  muciparous  uterus,  anterior  surface  ;  B,  uterine  cavity.    (Sappey.) 

branching  processes  extend  obliquely  upward,  giving  rise  to  an  appear- 
ance which  justifies  the  title — arbor  vitce  uterina. 

In  women  who  have  borne  children,  the  uterus  measures  three  inches 
in  length,  of  which  nearly  two  inches  belong  to  the  body  and  one  to 
the  cervix.     There  is  increased  convexity  of  the  fundus.     The  distance 


u 


PHYSIOLOGICAL   ANATOMY. 


between  the  insertions  of  tlie  Fallopian  tubes  measures  over  two  inches. 
The  width  of  the  cervix,  at  its  Junction  with  the  body,  measures  one 
inch.  The  uterus  thus  assumes  a  pyriform  shape.  The  cavity  of  the 
uterus  loses  its  triangular  character,  and  assumes  a  more  ovoid  ap- 
pearance. The  external  orifice  no  longer  forms  a  smooth  transverse 
depression,  but  its  edges,  lacerated  by  childbirth,  communicate  the 
impression  of  a  rounded,  puckered  surface. 

When  a  profile  section  is  made  through  a  perfectly  healthy  unim- 
/^^pregnated  uterus,  its  walls  are  found  in  actual  contact.  A  cavity  does 
not,  therefore,  naturally  exist. 

The  uterus  is  so  situated  in  the  pelvic  cavity  as  to  possess  a  large 
degree  of  mobility.     Its  lower  extremity  projects,  as  we  have  seen,  into 


Fig.  9. — Virgin  uterus  opeuecl  posteriorly,  showing  at  A,  A',  the  os  internum  ;  at  O,  e,  os  exter- 
num ;  P,  peritoneal  folds.    (Bandl.) 


the  vagina.  The  supra- vaginal  portion  of  the  cervix  is  attached  anteri- 
orly to  the  walls  of  the  bladder.  That  portion  of  the  uterus  which  ex- 
tends freely  into  the  pelvic  cavity  is  covered  by  a  reflection  of  the  pe'ri- 
tonseum,  precisely  as  though  the  uterus  had  been  pushed  from  below 
upward  into  the  peritoneal  sac.  Thus  the  peritonaeum  covers  the 
uterus  anteriorly  and  posteriorly.  Its  two  surfaces  meet  at  the  lateral 
borders  of  the  uterus,  and  thence  spread  outward  to  the  ilia  of  the 
respective  sides.  These  peritoneal  folds  divide  the  pelvic  cavity  into 
two  nearly  equal  halves,  and  are  termed  the  Ugametita  lata,  or  broad 
ligaments. 

Two  peritoneal  folds,  containing  a  few  contractile  fibers  derived 
from  the  muscular  tissue  of  the  uterus,  pass  forward  from  the  uterus 


FEMALE  OUGANS  OF  GENERATION. 


15 


to  the  bladder — the pUcce  vesico-ntcrince.  These  folds  form  the  sides 
to  a  space,  limited  anteriorly  and  posteriorly  by  the  bladder  and  uterus, 
termed  the  excavatio  vesico-uterina. 

Upon  the  posterior  surface,  the  peritoniBum  descends  down  not 
only  over  the  entire  supra- vaginal  portion  of  the  uterus,  but  over  that 
portion  of  the  vagina  which  covers  the  posterior  lip  of  the  intra-vagi- 
nal  portion.  Thence  it  curves  upward,  and  becomes  continuous  with 
the  peritoneal  investment  of  the  rectum.  Thus  a  deep  cul-de-sac  is 
formed  between  the  uterus  and  the  rectum,  known  as  the  excavatio 
recto-utevina^  or  cul-de-sac  of  Douglas.  Two  lateral  folds  of  peri- 
tonaeum likewise  pass  from  the  uterus  to  the  rectum,  which  form  sides 
to  this  space,  the  ^^//Vvp  yerfo-uterina>.      These  folds  inclose  in  their 


Fig.  10. — Uterus  of  a  woman  wlio  has  borne  children.    A,  A',  the  portion  of  the  uterine  cavity 
corresponding  to  the  peritoneal  folds,  P ;  B,  B',  os  internum  ;  O,  e,  os  externum.    (Bandl.) 


free  borders  contractile  muscular  fibers,  derived  from  the  uterus  and 
vagina.  The  plicae  recto-uteri nae  pass  backward,  near  the  rectum,  to 
the  neighborhood  of  the  second  sacral  vertebra.  As  the  muscular 
fibers  they  contain  were  believed  by  Luschka  to  fulfill  the  function 
of  maintaining  the  uterus  in  a  state  of  normal  anteversion,  he  proposed 
that  they  should  be  termed  the  retractores  uteri.  In  Figs.  9  and 
10,  copied  from  Bandl,  it  will  be  noted  that  in  the  virgin  uterus  the 
upper  borders  of  the  peritoneal  folds  which  bound  laterally  the  cul-de- 
sac  of  Douglas  leave  the  uterus  at  a  point  corresponding  very  nearly 
to  the  site  of  the  os  internum ;  whereas,  in  the  uterus  of  women  who 
have  borne  children,  the  os  internum  is   situated  at  a  considerable 


jg  PHYSIOLOGICAL   ANATOMY. 

distance  below  the  folds,  a  difference  whicb  Baudl  believes  to  be  due 
to  an  expansion  of  the  upper  portion  of  the  cervical  canal  by  the  growth 
of  the  ovum  during  pregnancy,  the  expanded  portion  thereafter  form- 
ing permanently  an  addition  to  the  uterine  cavity. 

The  peritonaeum  covering  the  uterus  is  an  exceedingly  delicate 
membrane.  Over  the  body. and  fundus  of  the  uterus,  both  front  and 
rear,  it  adheres  intimately  to  the  muscular  tissues,  while  below  the 
level  of  the  recto-uterine  folds,  where  the  subperitoneal  connective  tis- 
sue is  more  abundant,  separation  is  easily  effected. 

Though  it  may  be  proper  to  speak,  in  a  general  way,  of  the  uterus 
as  occupying  a  position  coincident  with  the  axis  of  the  superior  pelvic 
strait,  it  must  be  borne  in  mind  that,  in  reality,  its  position  is  largely 
influenced  by  the  neighboring  organs.  Thus,  a  full  bladder  pushes  the 
fundus  backward.  A  full  rectum  shoves  the  cervix  forward.  When 
bladder  and  rectum  are  both  evacuated,  the  resiliency  of  the  muscular 
fibers  in  the  recto-uterine  folds  produces  a  limited  amount  of  ante- 
version.  Marked  degrees  of  anteversion  or  anteflexion  following  the 
evacuation  of  the  bladder  are  abnormal,  and  are  due  either  to  fixation 
of  the  cervix  resulting  from  inflammatory  changes  in  the  parametrium, 
to  increased  size  of  the  uterus,  or  to  the  loss  of  the  muscular  tomis. 

The  uterus  is  composed  of  muscular  fibers  of  the  unstriped  variety, 
arranged  in  bundles  and  united  together  by  delicate  processes  of  con- 
nective tissue.  In  the  non-gravid,  but  more  distinctly  in  pregnant  and 
puerperal,  uteri  the  arrangement  of  the  muscular  fibers  in  three  layers 
is  indicated,  though  the  layers  are  not  absolutely  separable  from  one 
another. 

1,  The  superficial  layer  covers  tlie  anterior  and  posterior  surfaces 
of  the  uterus  like  a  hood,  while  the  sides  are  left  free.  It  possesses  a 
membranous  thinness,  and  is  intimately  adherent  to  the  peritonanim. 
Its  fibers,  a  part  of  which  are  continuous  with  the  longitudinal  fibers 
of  the  external  muscular  layer  of  the  Fallopian  tubes,  pursue  an  appar- 
ently circular  course  in  the  neighborhood  of  the  tubes  and  a  longitu- 
dinal direction  near  the  median  line. 

The  continuity  of  the  outer  layer  is,  however,  broken  by  the  inser- 
tions of  the  retractor  muscles,  and  of  the  ovarian  and  round  liga- 
ments. The  ovarian  ligament  is  a  broad  band,  measuring  about  an 
inch  in  length  and  a  fifth  of  an  inch  in  width,  which  passes  posteriorly 
from  the  upper  lateral  portions  of  the  uterus  between  the  layers  of  the 
broad  ligament  to  the  ovary.  The  round  ligament,  a  muscular  bundle 
of  rounded  form,  passes  from  the  anterior  uterine  surface  near  the  in- 
sertions of  the  Fallopian  tubes  between  the  peritoneal  folds  of  the 
broad  ligament  and  through  the  inguinal  canal  to  the  symphysis  pubis, 
where  its  fibers  terminate  in  the  connective  tissue  of  the  mons  Veneris. 
The  round  ligament  is  four  to  five  inches  in  length,  and  in  the  unim- 
pregnated  condition,  when  the  fundus  is  depressed  below  the  pelvic 


FEMALE  ORGANS  OF  GENERATION. 


lY 


brim,  runs  in  a  curved  direction  upward,  outward,  and  forward,  to  gain 
the  inguinal  ring. 

2.  The  median  layer  constitutes  the  great  bulk  of  the  uterine  walls. 
It  is  composed  of  longitudinal  and  transverse  fibers  which  form  an  in- 
tricate interlacement,  in  the  meshes  of  which  are  contained  the  vessels 
of  the  organ.  In  pregnancy  the  arrangement  of  muscular  bundles  in 
superimposed  leaf-like  plates  or  lamella3  is  observable.  These  start  in 
the  fundus  and  body  of  the  uterus  from  the  peritonaeum,  to  which  they 
are  firmly  attached,  and  at  first  the  fibers  are  in  close  proximity.  They 
soon,  however,  split  into  bundles,  which  follow,  in  most  cases,  an  oblique 
course  downward  and  inward  to  the  uterine  mucous  membrane.  In 
the  lower  uterine  segment,  i.  e.,  the  inferior  convex  portion  of  the  uter- 
ine cavity,  which  in  pregnancy  and  childbirth  is  subjected  to  the  dis- 
tending influence  of  the  presenting  part,  th§  muscular  lamellae — seven 
to  ten  in  number  (J.  Veit) — are  attached  to  the  peritonaeum  by  means 
of  loose  connective  tissue.  They  send  fibers  in  part  to  the  connective 
tissue  of  the  cervix,  and  in  part  to  that  which  surrounds  the  upper 
vaginal  walls. 

3.  The  inner  layer  is  of  extreme  tenuity.  Its  fibers  pursue  a  sjii- 
roidal  course  around  the  orifices  of  the  tubes.  Between  the  latter  and 
the  internal  os  the  fibers  of  the  inner  layer  form  on  the  anterior  and 
posterior  surfaces  beneath  the  mucous  membrane  a  triangular  muscle, 
and  extend  downward  into  the  cervix.  During  j^regnancy  the  triangu- 
lar muscles,  owing  to  their  fixation  at  the  internal  os,  do  not  follow  the 
expansion  of  the  uterine  cavity.  The  underlying  transverse  fibers  are 
therefore  exposed  upon  the  lateral  walls,  a  con- 
dition which  persists,  after  involution  is  com- 
plete (Bayer). 

The  cervical  walls  are  composed  mainly  of 
connective  tissue.  The  muscular  structures 
of  the  cervix  are  derived  from  the  lamella?  of 
the  lower  segment,  from  the  inner  layer  of  the 
uterus,  and  from  the  fibers  which  accompany 
the  distribution  of  the  vessels. 

Upon  the  outer  surface  of  the  cervix,  just 
at  the  point  of  the  vaginal  attachment,  there 
is  a  well-developed  layer  of  transverse  muscular 
fibers.  Circular  vessels,  imbedded  in  a  loose- 
meshed  connective  tissue  containing  wide  lym- 
phatic spaces,  surround  the  cervix  at  the  same 
point.  Thus  a  ridge  is  formed,  which  is  greatly  augmented  in  size 
during  pregnancy. 

In  the  cervix,  the  connective  tissue  exists  in  the  form  of  well-differ- 
entiated fibers  of  the  ordinary  variety.     In  the  body  of  the  uterus,  a 
similar  loose-meshed,  wavy  connective  tissue  is  found  in  the  external 
2 


Fig.  11.— S<'ction  tlirougli  tlie 
mucous  membrane  of  a 
normal  virgin  uterus, 
magnified  about  forty  di- 
ameters (Kundrat  and  En- 
gelmanni.  S,  mucous 
membrane  :  D. glands :  M. 
muscular  tissue  belonging 
to  the  internal  layer. 


18 


PHYSIOLOGICAL   ANATOMY. 


layer  where  it  sends  processes  "between  the  muscular  bundles,  and 
surrounds  the  vessels.  In  the  median  layer,  rings  of  connective 
tissue  accompany  the  vessels,  while  fibers  of  the  finest  description 
penetrate  between  the  muscular  bundles.  Fine  fibers,  of  a  like  char- 
acter, but  more  abundant,  are  found  in  the  inner  muscular  stratum, 
whence  they  pass  directly  into  the  connective  tissue  of  the  mucous 

membrane. 

The  mucous  membrane  of  the  uterus  is  divided  into  that  lining  the 
body  and  that  which  lines  the  cervical  portion,  between  which  charac- 
teristic differences  of  structure  exist. 

TJie  mucous  memhrane  of  the  hodij  is  smooth  and  soft.  ^  At  the  fun- 
dus and  upon  the  sides  it  measures  about  ^j  of  an  inch  in  thickness, 
but  is  thinner  in  the  vicinity  of  the  tubes  and 
the  cervical  portion.  It  is  covered,  under  nor- 
mal conditions,  with  a  thin  layer  of  transpar- 
ent alkaline  mucus.  AVhen  examined  with  a 
magnifying-glass  its  surface  presents  a  per- 
forated appearance,  due  to  the  openings  of 
the  uterine  glands.  These  glands  are  of  the 
tubular  variety,  have  a  sinuous  course,  and  are 
oftentimes  divided  below  into  two  or  three 
separate  blind  extremities.  They  extend,  in 
the  rule,  through  the  entire  thickness  of  the 
mucous  membrane,  and,  in  rare  instances, 
penetrate  into  the  muscular  tissue  of  the 
uterus.  They  possess  a  delicate  basement 
membrane,  composed  of  spindle-shai)ed  cells, 
which  dovetail  into  one  another  like  the  endo- 
thelium of  the  capillaries  and  lymphatics.* 
They  are  lined  by  cylindrical  cells  which  are 
said  to  possess  cilias.  The  mucous  membrane 
of  the  body  of  the  uterus  possesses  an  epi- 
thelium of  the  ciliated  variety,  which  produces 
a  current  in  the  direction  of  the  Falloi)ian 
tubes,  f 
A  very  irregular  capillary  net-work,  with  delicate  walls,  extends 
between  the  glands,  and  passes  near  the  free  surface  into  venous  radi- 
cles, which  furnish  during  menstruation  the  source  of  venous  haemor- 
rhage. 

The  intermediate  space  is  filled  up  by  a  connective-tissue  mesh-work, 
composed  of  fine  processes  and  spindle-shaped  cells,  whose  nuclei  im- 

*  Leopold,  Die  Lymphgefasse  des  normalen  nicht  schwangeren  Uterus,  Arch. 
I.  Gynaek.,  Bd.  vi,  1873,  Heft  1,  p.  33. 

t  V.  Strickeb,  Die  Lehre  der  Geweben,  Leipsic,  1871,  art.  Uterus,  von  Dr.  II. 
Chrobak,  pp.  1173  e^  seq. 


Fig.  12.— Section  through  ute- 
rus showing  cavity,  a,  and 
glandular  structures,  d. 
^Weber.) 


PEMALK  ORGANS  OP  GENKKATIOX.  ;19 

part  to  liardciied  specimens  a  granular  appearance.  Leopold  *  claims 
for  this  mesh-work  the.signiticance  of  lympli-siniises.  The  close  attach- 
ment of  the  mucous  membrane  to  the  muscular  tissue  is  explained  by 
the  direct  continuity  of  the  connective  tissues  of  the  two  structures. 

The  mucous  memhrane  of  the  cervix  is  of  a  yellowish-red  color,  of  ai 
firm  consistence,  and  possesses  the  penniform  ridges  already  described. 
It  is  therefore  readily  distinguished,  both  by  the  eye  and  the  touch, 
from  the  red,  smooth,  velvety  structure  of  the  mucous  membrane  lin- 
ing the  body.  At  the  time  of  puberty  it  possesses  a  ciliated,  cylindri- 
cal epithelium,  which  extends  down  to  within  from  two  to  three  lines 
of  the  OS  externum. f  Simple  gland-tubes,  and  glands  with  multiple 
cuJx-dc-sac,  are  found  upon  the  crests  and  sides  of  the  ridges  and  upon 
those  portions  of  the  cervical  canal  in  which  ridges  do  not  exist.  These 
glands  are,  genetically  considered,  simple  inversions  of  the  mucous  mem- 
brane, and  are  lined  by  ciliated  epithelium.  When  the  neck  of  one  of 
these  glands  becomes  obstructed,  the  secretion  accumulates,  and  forms 
the  straw-colored  vesicles  which  have  been  termed  the  ovula  of  Nabotli. 
Papillary  structures,  of  clavate  shape,  are  very  numerous  in  the  lower 
half  or  third  of  the  canal.  According  to  Lott,J  a  section  through  one 
of  these  papilla3  is  not  to  be  distinguished  from  a  section  through  one 
of  the  smaller  folds  of  the  arbor  vitai  uterina.  The  cervical  mucous 
membrane  affords  thus  an  extensive  secretory  surface,  furnishing  an 
alkaline  mucus,  Avhich"  possesses  important  physiological  functions  in 
connection  with  conception,  pregnancy,  and  labor. 

The  Fallopian  Tubes. — The  Fallopian  tubes,  as  the  history  of  their 
develo^iments  goes  to  demonstrate,  are,  strictly  speaking,  integral  por- 
tions of  the  uterus.  A  glance  at  Fig.  14  will  serve  to  make  apparent 
the  continuity  between  the  tissues  of  the  uterus  and  those  of  the  Fal- 
lopian tubes.  It  will  be  noticed,  too,  that  the  canal  of  the  latter  com- 
mi;nicates  directly  with  the  uterine  cavity.  The  Fallopian  tubes  meas- 
ure from  three  to  four  inches  in  length.  They  are  included  between 
the  folds  of  the  broad  ligament  at  its  upper  border.  As  they  pass  out- 
Avard  from  the  uterus  they  follow  a  somewhat  sinuous  course,  and  gradu- 
ally increase  in  width  and  thickness.  The  free  extremity  possesses  an 
opening  communicating  with  the  abdominal  cavity,  the  ostiinn  abdomi- 
nale,  which  is  large  enough  to  admit  a  small  goose-quill  {2"),  whereas 
the  uterine  opening  does  not  exceed  ^  of  an  inch  in  diameter.  Henle 
designated  the  inner,  narrower  half,  which  runs  a  comparatively  straight 
course,  the  isfhmus,  and  the  outer,  sinuous,  dilated  portion  the  amjmlla 
of  the  tube.  A  number  of  ragged,  fringe-like  processes  surround  the 
ostium  abdominale,  whence  the  name  fimhriated  extremity  of  the  ttibe. 
These  fringes  received  likewise  from  the  mediaeval  anatomists  the  name 

*  Op.  cit.,  p.  47. 

t  LoTT.  Zur  Anatomie  und  Physiologic  der  Cervix  Uteri,  Erlangen,  1872,  p.  17, 

X  LoTT,  I.  c,  p.  20. 


20 


PHYSIOLOGICAL  ANATOMY 


onorsui!  diahoU,  from  a  supposed  resemblance  to  the  root  of  the  seabiosa 
puccissa,  the  peculiar  appearance  of  which  was  ascribed  by  the  super- 


O.a. 


L-i.p. 


L.i.Q. 


X 

L.I. 


Fig.  13.— Posterior  lateral  view  of  the  aterus  (D".f.).  with  portion  of  lig.  latum  (L.I.),  oviduct, 
and  ovary.  Od,  isthmus  ;  Od',  ampulla  ;  Js  infundibulum  ;  O.a.,  ostium  abdQminale  ;  F.o., 
fimbria  ovarica  ;  O.  ovarium  ;  L.o.,  lis-  ovarii ;  L.i.o.,  lig.  infundibulo-ovaricum  ;  L.i.jp.,  lig. 
infundibulo-pelvicum  ;  Po.,  parovarium.    (Henle.) 

stitious  to  a  bite  the  devil  gave  it  in  a  lit  of  anger  at  its  beneficent 
action  in  the  maladies  that  affect  the  human  race.*     One  of  the  fim- 


■gyofo^^ 


Fig.  14.— Section  through  Fallopian  tube.    (Richard.) 


briffi  {F.o.)  is  rather  longer  than  the  rest,  and  is  attached  to  the  outer 
angle  of  the  ovary. 

The  muscular  avails  of  the  tubes  are  composed  of  unstriped  fibers, 
*  Hyrtl,  Topographische  Anatomic,  Wien,  1865,  Bd.  xi,  p.  210, 


FEMALE   OIKIANS   OF   CIENERATIUX. 


21 


similar  to  those  described  as  existing  in  the  uterus.  They  are  arranged 
in  three  layers :  two,  longitudinal,  continuous  respectively  with  the 
external  and  internal  layers  of  the  uterus  ;  and  one,  circular,  continuous 
with  the  circular  fibers  of  the  inner  uterine  layer.  Galvanization  of  the 
tubes  causes  contractions  of  a  vermicular  character. 

Between  the  muscular  walls  and  the  peritoneal  covering  there  is  a 
connective-tissue  layer,  which  gives  support  to  a  rich  plexus  of  blood- 
vessels. 


Fig.  15.— Section  througrh  ampulla  (thirty  diameters),  o.  submucous  tissue  ;  6,  muscular  layer ; 
c,  serous  coating  ;  d,  mucous  membrane  ;  e,  e.  vessels :  1,1,  little  folds,  resembling  villosi- 
ties  when  seen  in  profile  ;  2,  2,  longitudinal  folds  of  larger  size,  with  numerous  accessory 
folds :  3,  3,  little  folds,  united  together  so  as  to  form  a  sort  of  canalicular  net-work. 
(Luschka.) 


The  mucous  membrane  of  the  tubes  is  extremely  vascular,  and  has 
a  ciliated  epithelium,  which  produces  a  current  in  the  direction  of  the 
uterus.  It  presents  numerous  longitudinal  folds,  which  are  much  more 
complicated  in  the  ampulla  than  in  the  isthmus.  In  the  ampulla  these 
folds  possess  an  arborescent  character,  as  may  be  seen  in  Fig.  15. 

The  Ovaries. — The  ovaries  are  two  flattened,  nearly  ovoid  bodies, 
situated  between  the  layers  of  the  broad  ligament.  They  measure 
from  one  to  one  and  a  half  inch  in  length,  from  three  fourths  of  an 
inch  to  an  inch  in  breadth,  and  from  a  third  to  a  half  inch  in  thick- 
ness. Each'  ovary  is  connected  with  the  uterus  by  a  muscular  band 
about  an  inch  in  length  and  a  fifth  of  an  inch  in  width,  termed  the 
ligamcnium  ovarii. 


90 


PHYSIOLOGICAL   ANATO Jl Y. 


Previous  to  pxTbortv  tlie  ovaries  present  a  siiiootli  surface,  but  after 
maturity  tliey  become'  uneven  and  corrugated  from  the  enlargement, 
rupture^  and'cicatrization  of  the  Graafian  follicles. 

Although  the  ovaries  are  said  to  be  of  ovoid  shape,  in  reality  one 
border  is  much  more  convex  than  the  other.  The  comparatively 
straight  border  is  attached  to  the  posterior  surface  of  the  anterior 
layei^of  the  broad  ligament.  The  posterior  layer  of  the  broad  liga- 
ment is  reflected  over  the  entire  ovar^j,  Avith  the  exception  of  the  at- 
tached  l)()rder,   at   which    point   tlie   hilum,  or  opening,  is  situated. 

through  which  the  sper- 
matic vessels,  which  are  in- 
cluded between  the  folds 
of  the  broad  ligament,  find 
entrance  into  the  sub- 
stance of  tlie  organ.  Wal- 
deyer  *  has  shown  that  an 
abrupt  change  in  the  chai-- 
acter  of  the  epithelium 
from  the  pavement  to  the 
cylindrical  variety  takes 
place  where  the  perito- 
naeum reaches  the  hilum 
of  the  ovary.  At  this 
point,  too,  the  connective 
tissue  of  the  serous  mem- 
brane ceases  to  form  an 
independent  layer,  easily 
separable  from  the  under- 
lying tissues,  but  becomes 
lost  in  the  stroma  of  the 
ovary. 

When  the  broad  liga- 
ments are  removed  from 
the  body,  and  held  as 
nearly  as  possible  in  the 
natural  position,  the  con- 
vex border  of  the  ovary 
looks  downward.  If  the 
broad  and  ovarian  liga- 
ments are,  however,  put  upon  the  stretch,  the  convex  border  rises  and 
looks  directly  backward. 

The  ovary  is  found,  upon  section,  to  contain  a  fibrous  stroma,  the 

*  "Waldeyer,  Eierstock  uud  Nebeneierstock,  Strieker's  Handbuch  der  Lehre 
der  Geweben,  p.  545.  And  for  modification  of  Waldej'er's  earlier  views,  vide  Arehi- 
blast  and  Parablast,  Bonn,  1883,  p.  68. 


Fig.  16.— Longitudiual  section  of  ovary  from  a  i)frsou 
aged  eighteen  (eight  diameters).  1,  albuginea  ;  2, 
fibrous  layer  of  cortical  portion  ;  3.  cellular  layer  of 
cortical  portion  ;  4,  medullarj'  substance  ;  5,  loose 
connective  tissue  between  the  firm  layers  of  the  me- 
dullary substance.    (Henle.) 


FEMALE  ORGAXS  OF  GENERATION.  23 

arrangement  of  which  can  be  best  understood  by  reference  to  the  ac- 
companying excellent  illustration  from  Henle. 

Externally,  the  ovary  is  surrounded  by  a  fibrous  coating,  the  so- 
called  tunica  albuginea.  In  the  first  three  years  of  existence,  how- 
ever, the  albuginea  is  wanting.  Even  in  a  state  of  complete  develop- 
ment, it  can  never  be  stripped  off  as  a  separate  layer,  but  is  always 
intimately  adherent  to  the  subjacent  tissues. 

Beneath  the  albuginea  the  parenchyma  of  the  gland  is  further 
divided  into  an  outer  cortical  and  an  inner  medullary  substance. 

The  medullary  substance  has  a  spongy  texture,  and  is  of  a  reddish 
color.  It  contains  an  abundance  of  blood-vessels,  the  branches  of  which 
pursue  a  spiral  course.  The  cortical  subi^tance  is  of  a  grayish  color. 
In  it  a  multitude  of  small  follicles,  of  the  utmost  functional  impor- 
tance, lie  imbedded.  The  precise  description  of  these  follicles  will  be 
given  in  connection  with  the  subject  of  ovulation.  The  stroma  of  the 
cortical  substance  is  nowhere  sharply  distinguished  from  that  of  the 
medullary  portion.  The  fibers  of  the  stroma,  for  the  most  part,  radi- 
ate from  the  center  toward  the  circumference.  Just  underneath  the 
albuginea,  however,  the  connective  tissue  of  the  cortical  substance  pre- 
sents a  felted  arrangement.  This  portion  is  termed  in  the  illustration 
(Fig.  16)  the  fibrous  layer,  in  contradistinction  to  the  more  central 
portion,  which  is  largely  composed,  in  the  neighborhood  of  the  vessels 
and  the  follicles,  of  round  and  spindle-shaped  cells. 

The  Vessels  of  the  Uterus  and  its  Appendages. — The  uterus  receives 
its  arterial  supplies  from  the  following  sources:  1.  The  arferia  nter- 
ina  liypofiasfrira.  This  artery,  as  its  name  implies,  is  derived  from 
the  hypogastric.  It  first  pursues  a  downward  course  to  reach  the  vagi- 
nal fornix,  where  its  pulsations  may  be  felt  during  pregnancy.  Thence 
it  curves  upward  between  the  folds  of  the  broad  ligament,  and  follows 
a  tortuous  course  along  the  lateral  borders  of  the  cervix  and  corpus 
uteri.  It  distributes  small  branches  to  the  fornix  vaginae,  and  large 
ones  to  the  uterus.  Tlie  uterine  branches  are,  in  part,  distributed  to 
the  surface  of  the  uterus,  and,  in  part,  penetrate  the  muscular  tissue, 
to  form  a  thick  capillary  net-work  immediately  under  the  uterine  mu- 
cous membrane.  Of  surgical  interest  is  a  circumflex  branch,  which 
unites  the  arteries  of  each  side  with  one  another.  The  situation  of 
this  branch  is  just  at  the  junction  of  the  cervix  and  body.  During 
pregnancy  other  anastomotic  branches  are  developed.*  As  the  preg- 
nant uterus  is  situated  directly  under  the  abdominal  Avails,  the  arterial 
murmurs  are  at  certain  points  distinctly  appreciable,  and  furnish  the 
auscultatory   sign   of    pregnancy   improperly   termed   the   "placental 

*  Hyrtl  disputes  the  formation  of  anastomoses  during  pregnancy,  and  states 
that  in  the  pregnant  as  well  as  in  the  non-pregnant  uterus  none  but  capillary  com- 
munication exists  between  the  arteries.  Topographische  Anatomic,  Wien,  1865,  Bd. 
ii,  p.  194 


24 


PHYSIOLOGICAL  ANATOMY. 


bruit."  2.  The  arteria  uterina  aortica,  or  internal  spermatic  artery. 
The  origin  of  this  artery  is  situated  about  two  and  a  half  inches  above 
the  bifurcation  of  the  aorta.  It  pursues  a  serpentine  course,  and,  in 
places,  makes  spiral  turns,  which  are  specially  marked  during  preg- 
nancy. It  descends  obliquely  downward  under  the  peritonaeum  to  the 
cavity  of  the  pelvis,  and  then  ascends  between  the  folds  of  the  broad 
ligaments  to  reach,  by  its  branches,  the  ovary,  the  Fallopian  tube,  and, 

by  its  main  trunk,  the  side  of  the 
uterus,  where  it  forms  a  direct 
communication  with  the  art.  uter- 
ina hypogastrica. 

This  communication  between 
the  aortic  and  hypogastric  uterine 
arteries  serves  to  maintain  a  con- 
tinuous blood  current  during  ges- 
tation. The  situation  of  the  uter- 
ine artery  within  the  pelvic  cavity, 
and  its  exposure  to  pressure,  would 
render  it,  were  it  the  sole  source  of 
blood-supply,  an  extremely  unsafe 
dependence.  It  is  well  to  note 
here,  that  when  pressure  is  made 
upon  the  aorta,  after  childbirth, 
with  a  view  to  checking  posf-par- 
tum  haemorrhage,  the  manipulation 
fails  to  affect  in  any  way  the  blood- 
stream which  pours  into  the  uterus 
from  the  aortic  uterine  branches. 

The  beautiful  injections  of 
Rouget*  have  demonstrated  a  pe- 
culiar disposition  of  the  aortic  uter- 
ine branches,  as  they  penetrate  the 
body  of  the  uterus.  Instead  of  di- 
viding, as  they  branch,  dichoto- 
mously,  they  break  up,  on  reaching  the  vicinity  of  the  Fallopian  tubes, 
into  from  twelve  to  eighteen  arterial  tufts,  of  which  each  branch  is 
twisted  in  spiral  form.  These  tufts  of  vessels  are  so  aggregated  to- 
gether as  frequently  to  cover  the  angles  of  the  uterus. 

The  veins  of  the  uterus  form  a  net-work,  which  traverses  the  uter- 
ine tissues  in  all  directions.  As  their  walls  are  intimately  adherent  to 
the  muscular  tissues  of  the  uterus,  they  remain  ]iatulous  upon  section, 
and,  when  enlarged  by  pregnancy,  are  termed  "  sinuses.-"  Rouget  like- 
wise describes  twisted,  tangled  venous  tufts,  which  often  form  spirals 

*  Rouget,  Eecherches  sur  les  Organes  firectiles  de  la  Femrne,  Jour,  de  la 
Physiol.,  1858,  t.  i,  jip.  320  et  seq. 


Fia.  17.— Arterial  vessels  in  a  uterus  ten  days 
after  delivery  ;  the  uterus  is  turned  for- 
ward, so  as  to  present  the  posterior  as- 
pect. 1,  fundus  uteri ;  2,  vaginal  portion  , 
3,  3,  lig.  teres  ;  4,  4,  Fallopian  tubes  ;  5, 
right  ovary  ;  6,  abdominal  aorta  ;  7,  art. 
mesenterica  inf.  ;  8,  8,  art.  uterina  aortica 
(spermatic  arteries) ;  9,  9,  art.  iliaca  com- 
munis ;  10,  art.  iliaca  ext.  ;  11,  art.  hypo- 
gastrica ;  12,  art.  uterina  hypogastrica. 
(Lusehka.) 


FEMALE  ORGANS  OF  GENERATION. 


25 


like  those  described  in  the  arteries.  Tlie  same  authority  claims  that 
the  ultimate  divisions  of  the  arteries  communicate  with  the  venous 
sinuses  by  very  line  vessels,  measuring  from  ^o^th  to  -^^th  of  an  inch, 
instead  of  by  capillary  net- works. 

The  return-currents  of  the  uterus  empty  into  two  venous  plexuses : 

1.  The  plexus  uterinus.  This  plexus  receives  its  blood  from  the 
uterus  alone.  It  extends  between  the  folds  of  the  broad  ligament,  and 
empties  into  the  hypogastric  vein. 

2.  The  plexus  pci'iipi'iifonuis.  The  plexus  pampiniformis  derives 
its  blood  from  the  uterus,  the  Fallopian  tubes,  and  ovaries.  Its  vessels 
combine  to  form  a  single  trunk,  the  vena  spermatica  interna,  which 
follows  the  course  of  the  artery  of  the  same  name,  and  empties,  on  the 
left  side,  into  the  vena  renalis,  on  the  right  into  the  vena  cava. 


Fia.  18. — Uterine  ami  ntero-ovarian  veins  (plexus  painpinifonnis*.  1,  utenisiseen  from  the 
front ;  its  right  half  is  covered  bj-  the  peritonaeum  ;  upon  the  left  half  may  be  seen  the 
plexus  of  utero-ovarian  veins  (internal  spermatic) ;  6.  utero-ovarian  vessels  covered  by  peri- 
tonaeum :  7,  the  same  vessels  exposed  ;  8,  8,  8,  veins  from  the  Fallopian  tube  ;  9,  venous 
plexus  of  the  hilum  ovarii :  10,  uterine  vein  ;  11,  uterine  artery  ;  12,  venous  plexus,  cover 
ing  tile  borders  of  the  uterus  ;  13,  anastomoses  of  the  uterine  with  the  utero-ovarian  vein 
(int.  spermatic).     (Sappey.) 


The  m'teries  of  the  ovary  are  derived,  as  we  have  had  occasion  to 
notice,  from  the  internal  spermatic,  penetrate  the  medullary  substance, 
at  the  hilum  ovarii,  and  describe  a  spiral  course.  The  arterial  branches 
anastomose  within  the  ovary,  and  form  an  interlacement,  including 
spaces,  which  become  smaller  and  smaller  as  the  surface  of  the  gland 
is  approached.  The  veins  start  as  radicles  from  the  capillaries,  then 
rapidly  enlarge,  and  present  a  varicose  appearance.  By  their  anasto- 
moses they  form  a  plexus,  which  includes  spaces  of  very  irregular  size. 
The  blood  is  then  taken  up  by  venous  trunks,  which  run  parallel  to 
the  arterial  branches,  and  terminate  finally  in  the  internal  spermatic 
vein  (termed  by  Sappey,  Fig.  18,  the  utero-ovarian  vein). 

Upon  the  basis  of  the  foregoing  description  *  Rouget  draws  a  par- 
allel between  the  structures  of  the  penis  and  those  of  the  corpus  uteri, 

and  claims  identity  between  the  two  organs.     One  feature,  however,  of 
« 
*  Rouget,  Recherches  sur  les  Organes  ^firectiles  de  la  Pemrae,  Jour,  de  la  Physiol., 
t.  1,  pp.  338  et  seq. 


2g  PHYSIOLOGICAL   ANATOMY. 

the  erectile  tissue,  as  generally  understood,  is  wanting  in  the  uterus, 
viz  a  dense,  fibrous  sheath,  a  tunica  albuginea,  inclosing  the  erectile 
or^rln  limiting  the  degree  of  its  distention  and  enhancing  its  turgidity 
"as  experimental  proof  that  the  uterus  possesses  erectile  properties, 
Eou-et  has  shown  that,  when  an  injection  is  forced  by  the  spermatic 
arter^y,  in  the  dead  subject,  so  as  completely  to  distend  the  vessels  of 
the  body  of  the  uterus,  the  latter  becomes  elevated  in  the  pelvis,  and 
makes  a  movement  similar  to  that  performed  by  the  penis  during 
venereal  excitement. 

It  is,  however,  obvious  that  the  forcible  distention  of  the  vessels  of 
a  flaccid  uterus,  in  which  the  muscular  walls  are  deprived  of  their 
normal  tonus  by  death,  does  not  necessarily  represent  the  phenomena 
produced  during  life  by  the  turgescence  resulting  from  either  ovula- 
tion or  the  sexual  orgasm.  Unfortunately,  so  far  as  the  body  of  the 
uterus  is  concerned,  the  difficultiss  in  the  way  of  direct  observation 
upon  the  living  subject  have  hitherto  rendered  the  settlement  of  this 
point  impossible. 

With  regard  to  the  cervix  uteri,  we  have  physiological  as  well  as 
anatomical  reasons  for  admitting  a  certain  kind  of  erectility.  To  be 
sure,  a  tunica  albuginea  is  wanting.  It  is,  therefore,  not  an  ideal  erect- 
tile  oro-an.  But  it  is  among  the  occasional  unpleasant  exijeriences 
of  gynecological  practice  that  a  simple  digital  examination,  made  for 
the  purpose  of  a  diagnosis,  may  evoke  the  venereal  orgasm.  Precise 
observations  as  to  the  phenomena  presented  by  the  accessible  portion 
of  the  uterus  during  the  orgasm  have  been  furnished  by  Wernich,* 
Litzmann,f  and  in  one  remarkable  case  by  Beck,  \  which  leave  very 
little  doubt  that  strong  erotic  excitement  is  attended  by  a  rigidity  of 
the  cervix,  which  produces  an  impression  upon  the  fingers  similar  to 
that  imparted  by  the  glans  of  the  male  organ  during  erection. 

The  following  anatomical  peculiarities  of  the  cervix  uteri  are  fur- 
nished by  Henle  :  The  walls  of  the  vessels  (arteries,  capillary  branches, 
and  veins)  are  characterized  by  an  extraordinary  development  of  the 
circular  layer  of  muscular  fibers.  For  instance,  in  vessels  measuring 
from  -gxro"  ^^  To7  of  an  inch,  the  diameter  of  the  bore  is  scarcely  one 
third  the  diameter  of  the  entire  vessel.  The  arrangement  of  the  ves- 
sels is  likewise  peculiar.  In  the  labia  uterina,  especially  within  the 
muscular  tissues,  small  branches  pass  directly  down  to  the  mucous  sur- 
face. These  branches  pursue  an  undulatory  course,  are  parallel-,  and 
run  at  nearly  equal  distances  from  one  another.  Just  beneath  the 
mucous  surface  in  like  manner  the  veins  arise  and  make  their  way  up- 
ward parallel  to  the  arteries,  and  with  the  same  orderly  arrangement. 

*  Werxich,  Die  Erectionsfahigkeit  des  unteren  Uterus- Abschnittes,  Beitr.  zur 
Geburtsh.  und  Gynaek.,  Bd.  i,  p.  296. 

f  Wagner  s  Handworterbuch  der  Physiologie,  Bd.  iii,  p.  .53. 

X  Beck,  How  do  the  Spermatozoa  enter  the  Uterus?  Am.  Jour.  Obst.,  Nov.,  1874. 


FEMALE  ORGANS  OF  GENERATION.  27 

The  capillary  connections  between  these  veins  and  arteries  are  situated 
just  beneath  the  epithelium,  where  they  form  looped  projections  into 
the  papilhv.  In  the  pliciv  palinata^  the  general  direction  of  the  vessels 
is  likewise  perpendicular  to  the  surface.  In  commenting  upon  these 
facts,  Ilenle  remarks  that  there  is  nothing  in  the  situation  of-  the 
arterial  walls  that  would  call  for  their  special  development,  as  they  are 
not  ])articularly  exposed  to  external  pressure.  "  Where,  liowever,"  he 
says,  "  extraordinary  means  are  employed  in  maintaining  contraction, 
extraordinary  relaxation  and  dilatation  are  possible."  He  therefore 
premises,  as  at  least  probable,  "  that  the  changing  degrees  of  contrac- 
tility in  the  finer  vessels  may  serve  to  impart  a  sort  of  capacity  for 
erection,  or,  at  least,  turgescence,  to  the  cervical  and  vaginal  portion  " 
— an  anatomical  deduction  sustained,  as  we  have  seen,  by  physiological 
observation. 

A  similar  atteiii])t  on  the  part  of  M.  Rouget  to  constitute  an  erect- 
ile organ  out  of  the  ovai-y  is  disposed  of  by  Sappey  as  follows : 
"  Erectile  tissue  is  formed  by  large,  short,  anastomosing  capillaries, 
supporting  muscular  trabecula?,  and  into  which  open  the  ultimate 
divisions  of  the  arteries;  but  in  the  bulb  (the  vascular  portion  of  the 
ovary)  there  are  neither  dilated  capillaries,  nor  areolae,  nor  trabeculse. 
The  analogy  signalized  l)y  M.  Rouget  is  thei-efore  much  more  apparent 
than  real."'  ^ 

The  Nerves. — The  nerves  of  the  uterus  are  derived  from  the  gan- 
gliated  cords  of  the  sympathetic  system,  through  which  important 
connections  are  formed  with  all  the  abdominal  viscera.  Just  at  the 
bifurcation  of  the  aorta  there  is  a  broad  band  of  nerve  tissue  termed 
the  plexus  uferinvs  magnus,  formed  by  the  coalescence  of  filaments 
from  the  spermatic  ganglia  (two  i^airs  of  ganglia,  situated  upon  each 
side  of  the  inferior  mesenteric  artery)  and  filaments  derived  from  that 
]iortion  of  the  aortic  plexus  which  is  distributed  mainly  to  the  supe- 
rior mesenteric  artery  (plexus  mesentericus  superior,  Frankenhaeuser).f 
About  an  inch  and  a  half  below  the  bifurcation  of  the  aorta  it  divides 
into  two  strands,  the  plexnf<  Jn/pof/asfrici,  which  pass  right  and  left 
around  the  rectum  to  the  uterus  and  upper  portion  of  the  vagina. 
The  hypogastric  plexuses  receive  nerve  branches  from  the  lower  lum- 
bar and  three  upper  sacral  ganglia.  Upon  the  sides  of  the  rectum 
they  divide  each  into  two  jiortions,  of  which  the  smaller  passes  directly 
to  the  posterior  and  lateral  w^alls  of  the  uterus,  while  the  larger  con- 
tributes to  the  formation  of  the  cervical  ganglion. 

The  cervical  ganglion  (Frankenhaeuser)  is  not,  according  to  Jastre- 
botf,;|:  a  separate  organ,  but  a  large  plexus  comi:>osed  of  many  ganglia, 

*  Traite  d'Anatomie.  Paris,  1874,  vol.  iv,  p.  691. 
+  Frankexhaeuser,  Die  Nerven  der  Gebarmutter,  Jena,  1867. 
X  Jastreboff.  Anatomy  of  the  Gangjion  Cervicale  Uteri,  London  Obst.  Trans., 
vol.  xxiii,  p.  266. 


28 


PHYSIOLOGICAL   ANATOMY 


which  measures  during  pregnancy  two  inches  in  length  by  one  and  a 
half  inch  in  breadth.  It  is  formed  by  the  concurrence  of  filaments 
from  the  hypogastric  plexus,  the  three  upper  sacral  ganglia,  and  the 


Fia.  19.— Nerves  of  the  uterus.  A,  plexus  uterinus  niagnus  ;  B,  plexus  liypogastricus  ;  C,  cer- 
vical ganglion.  1,  sacrum  ;  2,  rectum  :  3.  bladder  ;  4.  uterus  ;  5,  ovary  ;  6,  extremity  of 
Fallopian  tube.    (Frankenhaeuser.) 

first,  second,  and  third  sacral  nerves.  The  cervical  ganglion  supplies 
the  entire  uterus,  and  especially  the  cervical  portion,  with  nerves. 
Examined  with  the  naked  eye,  these  nerves  are  soon  lost  sight  of  as 
they  penetrate  the  walls  of  the  uterus,  but  their  ultimate  filaments  have 
been  traced  by  Frankenhaeuser,  in  microscopic  preparations,  to  the 
muscular  element,  where  they  apparently  terminate  in  the  nucleus  of 
the  fiber- cell. 

The  Lymphatics.— We  have  already  had  occasion  to  notice  the  prob- 


FEMALE  ORGANS  OF   GENEKATIUX. 


29 


Fk;.  20.— Rudimentary  sexual  organs. 
The  internal  cirgans  represented  at 
the  seventh  week  of  fetal  Ufe  ;  the 
external  organs  belong  to  a  later 
period.  1,  spinal  column  ;  3,  3. 
AVolffian  bodies  ;  5,  glands  destined 
to  become  the  ovaries  in  the  female, 
the  testicles  in  the  male  ;  6,  Wolff- 
ian duct  ;  7,  filaments  of  Jliiller  ; 
8,  bladder  ;  9,  tubercle,  forming  the 
rudiment  of  either  the  clitoris  or 
penis  :  10,  folds  destined  to  form 
the  labia  majora  (in  the  male  the 
scrotum);  11,  sinus  uro-genitalis  ; 
12,  anus.    (Luschka.) 


able  existence  of  lymph-spaces  in  the  uterine  mucous  membrane.  In 
the  niusenlar  tissue  of  the  uterus,  lymph-spaces  are  found  in  the  deli- 
cate connective  tissue  which  unites  the 
muscular  bundles  together.  Regular 
lymphatic  veissels  are  found  in  the  con- 
nective tissue  which  accompanies  the 
arterial  trunks  into  the  uterine  paren- 
chyma. A  net-work  of  lymphatic  ves- 
.sels,  with  dilated  and  constricted  por- 
tions, and  provided  with  valves,  exists 
beneath  the  serous  coat.  The  lymph- 
.-paces  of  the  uterine  mucous  mem- 
l)rane  communicate,  by  funnel-shaped 
depressions,  with  the  lymph-spaces  and 
lymphatics  of  the  muscular  strata.  Just 
beneath  the  external  muscular  layer, 
upon  the  lateral  borders  of  the  uterus, 
are  large  receiving  vessels,  into  which 
empty  the  lymphatics  from  both  the 
subserous  and  uterine  vessels.  The 
lymphatics  of  the  cervix  pass  to  the 
glands  of  the  pelvic  cavity,  while  those 
of  the  border  and  fundus  follow  the 
course  of  the  plexus  pampiniformis  to  form  connections  with  the 
lymphatics  of  the  lumbar  region.* 

Deyelopmext  of  the  Female 
Generative  Organs. — Three  con- 
nected structures  make  their  ap- 
pearance on  either  side  of  the  spinal 
column,  at  an  early  period  of  fetal 
existence,  which  need  to  be  under- 
stood by  those  who  would  gain  a 
clear  idea  of  the  developed  organs 
of  generation  in  the  female.  These 
structures  are  the  Wolffian  bodies, 
the  ducts  of  j\[uller,  and  the  rudi- 
mentary organs  Avhich  are  destined 
at  a  more  advanced  period  to  be- 
come the  ovaries. 

The  Wolffian  bodies  are  oblong 
glandular   structures,  temporary  in  character,  which  are  thought  to 
perform,  in  the  embryo,  the  excretory  function  of  the  kidney.     They 

*  Leopold,  Die  Lymphgefasse  der  normalen  nicht  schwangeren  Uterus,  Arch, 
f.  Gynaek.,  Bd.,  vi,  Heft  I,  pp.  1  et  seq. ;  Luschka,  Die  Anatomie  des  menschliclien 
Beckens,  Tubingen,  1865,  p.  378. 


Fig.  21.— Uterus  and  its  appendages  in  the 
fcBtus  at  the  end  of  the  fourth  month 
(natm-al  size).  A.  external  view  ;  «,  a, 
ovaries,  relatively  large,  nearly  as  long 
as  the  oviducts  ;  h,  6,  the  Fallopian  tubes 
(oviducts);  c,  c,  round  ligaments;  d, 
uterus  ;  <-,  vagina  ;  /,  vaginal  orifice.  B, 
interior  view  ;  a.  rami  of  the  arbor  vitae, 
extending  to  the  fundus  of  the  uterus  ; 
6,  vaginal  portion  of  utei-us  ;  c,  vagina. 
(Courty.) 


8U 


PHYSIOLOGICAL   ANxVTO.MY. 


possess  ducts,  situated  at  the  sides,  wliicli  converge  together  below  the 
Wolffian  bodies  to  empty  into  the  sinus  uro-genitalis. 

Two  organs,  destined  to  become  the  orarics,  make  their  appearance 
upon  the  iliner  side  of  the  Wolffian  bodies.  They  possess  at  first  an 
elongated,  but  subsequently  assume  a  more  oval  appearance. 

The  ducts  of  Miiller  are  secondary  formations,  and  are  produced  by 
an  inversion  of  the  peritoneal  epithelium,  beginning  near  the  anterior 
end  of  the  Wolffian  body  and  thence  extending  downward  parallel  to 
the  Wolffian  ducts.  (Kolliker.)  Below  they  pass  spirally  forward, 
where  they  meet  in  the  median  line,  to  descend  together  to  the  sinus 


Fig.  23.— Uterus  unicornis  from  a  young  child,  posterior  asi>ect  (Pole),  o.  uterus  unicornis,  left 
half  of  uterus  undeveloped  ;  6,  right  Fallopian  tube  ;  c,  left  Fallopian  tube,  exceptionally 
present ;  d,  d,  ovaries  ;  e,  bladder.    (Courty.) 

uro-genitalis.  By  the  eighth  week  the  lower  portions  of  the  filaments, 
which  are  in  apposition  with  one  another,  fuse  together,  and  furnish 
the  first  rudiments  of  the  uterus  and  vagina.  The  free  portions  of  the 
filaments  become  the  Fallopian  tubes.  Both  uterus  and  vagina  are  at 
first  divided  into  two  parts  by  a  common  partition-wall,  which  disap- 
pears subsequently  from  below  upward. 

Bayer  (Freund's  Gynakolische  Klinik,  Bd.  i,  p.  412  et  seq.)  regards  the 
uterus  as  derived  not  alone  from  the  ducts  of  Mllller,  but  that  tlie  retractors, 
the  round  ligaments,  and  the  ovarian  ligaments  likewise  contribute  to  the  forma- 
tion of  its  muscular  structures.  In  the  Fallopian  tubes  there  are  tlnee  layers  of 
muscular  tissue,  viz.,  the  external  and  internal  longitudinal  layers  and  the 
median  layer,  whose  fibers  run  in  a  transverse  direction.  The  fusion  of  the 
tubes  forms,  as  it  were,  the  frame  upon  which  the  uterus  is  built.  From  the 
external  and  internal  longitudinal  fibers  are  derived  the  longitudinal  fibers  of 
the  outer  and  inner  layers  of  the  uterus.  The  spirals,  which  aae  observable 
at  the  uterine  cornua,  are  formed  from  the  longitudinal  fibers  by  a  semirotation 
of  the  tubes  from  before  backward  at  their  point  of  union  Avith  the  uterus.  The 
transverse  fibers  in  the  median  layer  oi  the  tubes  persist  as  circular  fibers  in  the 
uterus.  The  retractor  muscles  pass  to  the  lower  portion  of  the  cervix,  are 
thence  reflected  upward,  and  their  fibers  cross  at  the  level  of  the  internal  os. 


FEMALE  ORGANS  OF  GENERATION. 


31 


At  each  point  in  their  course  they  give  off  fibers  to  the  substance  of  the  uterus 
and  contribute  the  principal  share  to  the  median  layer  of  the  lower  uterine  pole 
and  of  the  cervix,  forming  an  interlacement  with  the  other  muscular  bundles. 
The  chief  mass  of  the  posterior  wall  of  the  body,  and  of  the  layers  surrounding 
the  cornua,  are  derived  from  the  ovarian  ligaments,  while  the  outer  layer  of  the 
anterior  wall  of  the  corpus,  of  the  lower  portion  of  the  cervix,  and  the  entire 
supravaginal  portion  are  derivative  from  the  round  ligaments.  The  median 
layer  of  the  fundus  is  composed  of  fibers  derived  from  both  the  round  and  ova- 
rian ligaments. 

The  uterus,  at  the  fourth  month  of  fetal  life,  presents  distinct  traces 
of  the  early  origin  from  the  ducts  of  Miiller.     The  fundus  is  undevel- 


Fig.  23.— Double  uterus  and  vagina  from  a  girl  aged  nineteen  (Eisenmann).  a,  double  vaginal 
orifice  with  double  hymen  ;  6,  meatus  urethras  ;  c.  clitoris  ;  d,  urethra  ;  e,  e,  the  double 
vagina  :  /,  /,  uterine  orifices  ;  g,  r/,  cervical  portions  ;  h,  h,  bodies  and  cornua  ;  i,  i,  ovaries  ; 
k,  k.  Fallopian  tubes  :  I,  I,  round  ligaments  ;  Hi,  m,  broad  ligaments.    (Courty.) 


oped.     The  ridges  of  the  arbor  vitse  uterina,  which  are  confined  at  a 
later  period  to  the  cervix,  extend  the  entire  length  of  the  uterus.     A 


38 


PHYSIOLOGICAL  ANATOMY. 


Fio.  24.— Uterus  bicornis,  double  cavity  and  double  vagina,  from  a  girl  seventeen  years  of  age. 
c,  cervical  portions  united  together,  presenting  the  appearance  of  a  single  cervix  ;  d,  d,  the 
two  cornua.    (Schroeder.) 


I 


Fig.  26.  —Uterus  cordiformis,  double  natural  size.    (Kussmam. 


FEMALE  ORGANS  OF  GENERATION. 


33 


depression  at  the  fundus  marks  the  point  of  union  between  the  ducts 
of  MuUer.  Two  eornua,  or  horns,  are  thus  distinguishable  upon  the 
external  surface  of  the  uterus.  About  the  eighth  or  ninth  month  the 
convex  fundus  is  developed,  and  the  eornua  disappear  externally,  though 
all  through  life  they  are  traceable  upon  the  inner  surface  in  lateral  sec- 
tions of  the  uterus  (ride  Fig.  15,  p.  21). 

Before  the  differentiation  of  sex  has  taken  place,  the  external  organs 
of  generation  present  the  following  appearances  :  Two  ridges,  or  folds, 
surround  a  central  opening  (sinus  uro-genitalis),  which  either  unite  to 
form  the  scrotum  of  the  male,  or  develop  into  the  labia  majora  in  the 
female.  Where  these  folds  join  together  above,  there  is  a  small  pro- 
jecting body,  or  tubercle,  destined  to  become  the  penis  or  the  clitoris. 
In  either  case  the  lower  surface  of  the  tubercle  is  furnished  with  a 
groove.  The  margins  of  the  groove  extend  along  the  sides  of  the  sinus 
uro-genitalis,  and,  in  the  development  of  the  female  type,  become  the 


FiQ.  26.— uterus  septus  bilocularis.    Double  uterus,  with  simple  vagina,  seen  from  the  front. 
Left  walls  more  developed  in  consequence  of  pregnancy.    (Cruveilhier.) 


labia  minora.     The  sinus  uro-genitalis  affords  a  common  aperture  for 
the  bladder  and  internal  organs  of  generation. 

Abnormalities  of  the  Uterus. — An  arrest  of  fetal  development 
gives  rise  to  a  number  of  deviations  from  the  ordinary  uterine  type,  of 
3 


34 


PHYSIOLOGICAL  ANATOMY. 


which  we  borrow  from  Courty  the  following  as  of  direct  obstetrical  im- 
portance : 

1.  Uterus  Unicornis.— The  one-horned  uterus  results  from  the  atro- 
phy or  incomplete  development  of  one  of  the  filaments  of  Miiller,  while 
the  other  continues  its  evolution.  We  then  have  a  uterus  which  is  com- 
posed of  a  single  lateral  half,  possessing  generally  but  one  Fallopian  tube. 

2.  Uterus  Duplex,  or  Didelphys. — Both  filaments  of  Miiller  are  de- 
veloped, but  do  not  become  united  together.  Thus  two  distinct  uteri  are 
produced,  of  which  each  represents  in  reality  the  half  of  a  normal  uterus. 

3.  Uterus  Bicornis. — Partial  union  of  the  filaments  of  Miiller  takes 
place,  but  without  reaching  the  ordinary  level  indicated  by  the  inser- 
tions of  the  round  ligaments.  The  upper  portion  of  the  uterus  is  thus 
divided  into  two  horns,  separated  by  a  furrow  from  one  another. 

4.  Uterus  Cordiformis. — The  uterus  remains  of  the  fetal  type  indi- 
cated in  Fig.  25.  Instead  of  a  complete  development  of  the  fundus, 
the  latter  remains  depressed,  and  presents  an  appearance  remotely  re- 
sembling the  heart  of  a  playing-card. 

5.  Uterus  Septus  Bilocularis. — Complete  union  of  the  two  filaments 
of  Miiller  has  taken  place,  but  the  common  wall,  formed  by  their  co- 
alescence, persists.  We  have  thus  two  distinct  uterine  cavities.  The 
septum  may  extend  the  whole  length  of  the  vagina,  and  give  rise  to  a 
double  vagina ;  or  absorption  of  the  vaginal  septum  and  a  portion  of 
the  uterine  septum  may  have  taken  place,  so  that  we  may  have  a  double 
uterine  cavity  with  a  single  cervix,  vfrrns  semi-partitus. 


Fig.  27.— Uterus  semi-partitus.    (Gravel.) 


PHYSIOLOGY  OF  THE  OVUM. 


CHAPTER  11. 


DEVELOPMENT  OF  THE  OVUM. 

The  Graafian  follicles  and  the  ovum. — Discharge  of  the  ova  from  the  ovary,  and  the 
formation  of  the  corpus  luteura. — The  migration  of  the  ovum. — Fecundation. — 
Changes  taking  place  in  the  ovum  subsequent  to  fecundation. — Nourishment  of 
the  embryo. — The  allantois  and  chorion. — The  deciduie. — The  placenta;  its  de- 
velopment and  structure. — Formation  of  the  umbilical  cord. — The  amniotic 
fluid. 

The  physiology  of  the  ovum  comprises  its  genesis,  development, 
and  discharge  from  the  ovary,  its  fecundation,  and  the  entire  series 
of  subsequent  changes  by 
which  the  simple  structure 
of  the  germ  becomes  con- 
verted into  a  complex  or- 
ganism presenting  the  spe- 
cific characteristic  of  the 
parent. 

The  following  account 
of  the  history  of  the  ovum 
is  derived  in  great  measure 
from  Waldeyer.* 

The  GKAAFI.A.N"  Fol- 
licles AND  THE  Ovum. — 
In  the  embryo  of  the  chick, 
by  the  fourth  day  of  incu- 
bation, the  Wolffian  body 
is  covered  by  cylindrical 
epithelium,  contrasting 
sharply  with  the  flattened 
cells  of  the  peritonaeum. 
Soon  after,  a  thickening 
of  the  epithelium  becomes 
noticeable  on  the  inner  side, 
and  forms  the  earliest  trace 


Fig.  28.— Section  of  Wolffian  body,  with  rudimentary 
ovary  (embryo  of  chick,  fourth  day  of  incubation). 
WK,  Wolffian  body  ;  y,  section  of  Wolffian  duct ; 
a,  a,  thickened  epithelium  ;  2,  duct  of  Muller  ;  E, 
early  stage  in  development  of  ovary  ;  O,  O,  primor- 
dial ova  ;  m,  mesentery  ;  i,  lateral  wall  of  abdomen. 
(Waldeyer.) 


*  Eierstock  und  Nebeneierstock,  Strickeb's  Handbuch  der  Lehre  von  den  Gewe- 
ben,  Leipsic,  1871 ;  Eierstock  und  Ei,  Leipsic,  1870. 


36 


PHYSIOLOGY  OF  THE  OVUM. 


of  the  ovary     Next,  a  small  rounded  elevation,  rich  in  cells,  and  derived 
from  the  interstitial  tissue  of  the  Wolffian  body,  makes  its  appearance 
underneath  the  thickened  epithelium.     The  epithelium  is  destined  to 
form  the  Graafian  follicles  and  ova;  the  proliferated  connective  tissue 
furnishes  the  vascular  stroma  of  the  ovary.     Between  the  fourth  and 
fifth  day  certain  cells  already  indicate  their  destiny  as  future  ova  by 
their  size,  their  rounded  shape,  and  large  nuclei.     The  further  develop- 
ment of  the  ovary  is  the  result 
of  the  multiplication  of  the  epi- 
thelial cells  and   the  continued 
growth  of  the  stroma.     As  the 
connective-tissue  processes  grow 
outward  and  penetrate  between 
the  cells,  the  latter  gradually  be- 
come  imbedded   in  the  stroma. 
Thus,  the  connective-tissue  pro- 
cesses   assume   a  trabecular  ar- 
rangement, the  meshes  of  which 
are  filled  with  cell-masses  of  a 
nearly  cylindrical   shape,  which 
hang  together  in  the  form  of  a 
net-work.    Among  the  imbedded 
cells,  the  large  ones  already  no- 
ticed   are    termed    "primordial 
ova."     The  smaller  cells  remain 
small,  and    arrange    themselves 
like  epithelium  around  the  larger 
ones.     In  the  course  of  develop- 
ment, the  interpenetration  of  the 
connective  tissue  continues,  until 
each    primordial   ovum   is  con- 
tained in  its  own  separate  par- 
tition.     These   partitions,   with 
the  included  cells,  are  rudiment- 
ary Graafian  follicles.     Two  dis- 
tinct ova  within  the  same  Graafian  follicle  are  of  rare  occurrence.     As 
the  ova  enlarge  and  the  epithelial  cells  multiply,  an  irritative  action 
is  set  up  in  the  surrounding  stroma.     An  increase  in  vascularity  re- 
sults, and  young  connective  tissue  is  developed  about  each  epithelial 
collection.     As  the  follicle  grows,  the  outer  layer  becomes  fibrillated. 
Thus  around  each  Graafian  follicle  a  distinct  .envelope  is  formed, 
termed  by  Baer  the  tJieca  folUcuU,  consisting  of  an  internal  vascular 
coat,  the  tunica  propria,  and  an  external  fibrillated  coat,  the  tunica 
fibrosa. 

Each  primordial  ovum  is  at  first  encircled  by  a  single  layer  of  cylin* 


Fia. 


.  29.— Section  through  portion  of  the  ovary 
of  mammal,  illustrating  mode  of  develop- 
ment of  the  Graafian  follicles  ( Wiedersheim). 
D,  discus  proligerus  ;  Ei,  ripe  ovum  ;  G,  fol- 
licular cells  of  germinal  epithelium;  g,  blood- 
vessels ;  K,  germinal  vesicle  (nucleus)  and 
germinal  spot  (nucleolus)  ;  KE,  germinal 
epithelium  ;  L/,  liquor  folliculi ;  Mg,  mem- 
brana  or  tunica  granulosa,  or  follicular  epi- 
thelium ;  Ml),  zona  pellucida  ;  PS,  ingrowths 
from  the  germinal  epithelium,  ovarian  tubes, 
by  means  of  which  some  of  the  nests  retain 
their  connection  with  the  epithelium ;  S, 
cavity  which  appears  within  the  Graafian 
follicle  ;  So,  stroma  of  ovary  ;  ly,  theca  fol- 
liculi or  capsule  ;  [7,  primitive  ova.  When 
an  ovum  with  its  surrounding  cells  has  be- 
come separated  from  the  nest,  it  is  known  as 
a  Graafian  follicle. 


DEVELOPMENT   OP   THE   OVUM. 


37 


drical  cells.  Gradually  new  layers  form,  in  which  the  ovum  lies  im- 
bedded. Afterward,  at  a  point  remote  from  the  ovum,  a  crescent- 
shaped  opening  makes  its  appearance,  which  becomes  filled  with  a  clear 
fluid  derived  from  transuded  serum,  and  in  part  from  liquefied  epithe- 
lium. A  heap  of  cells  remains  about  the  ovum  and  forms  the  discus 
proligerus.     With  the  increase  of  the  follicular  fluid  the  cylindrical 


Fig.  30.— Sagittal  section  of  the  ovary  of  an  adult  bitch  (after  Waldeyer).  o.  e,  ovarian  epi- 
thelium ;  o.  t,  ovarian  tubes  ;  y.  f,  younger  follicles  :  o.  /,  older  follicle  :  d.  p,  discus  pro- 
ligerus, with  the  ovum  ;  e.  epithelium  of  a  second  ovum  in  the  same  follicle  ;  /.  c,  fibrous 
coat  of  the  follicle  ;  p.  c,  proper  coat  of  the  follicle  ;  e.  /,  epithelium  of  the  follicle  (niem- 
brana  granulosa)  ;  a./,  collapsed  atrophied  follicle  ;  b.  v,  blood-vessels  :  c.  t,  cell-tubes  of 
the  parovarium,  divided  longitudinally  and  transversely  ;  t.  d,  tubular  depression  of  the 
ovarian  epithelium,  in  the  tissue  of  the  ovary  ;.6.  e,  beginning  of  the  ovarian  epithelium, 
close  to  the  lower  border  of  the  ovary. 

cells  are  pressed  against  the  membrana  propria,  and  form  a  third  coat- 
ing, or  layer,  termed  the  memhrana  granulosa. 

A  glance  at  a  transverse  section  through  the  ovary  of  a  mature  mam- 
mal exhibits  follicles  of  different  ages.     To  recapitulate : 


3g  PHYSIOLOGY   OF  THE   OVUM, 

The  young  follicles  are  composed  of  primordial  ova,  surrounded  by 
epithelium,  and  imbedded  in  the  ovarian  stroma. 

The  fully  developed  follicles  possess  a  vesicular  character.  They 
are  surrounded  by  a  connective-tissue  wall  (theca  folliculi),  which  is 
composed  of  two  layers  (tunica  propria  and  tunica  fibrosa).  The  tunica 
propria  is  lined  by  cells  (membrana  granulosa),  which  are  gathered  in 
heaps  (discus  proligerus)  around  the  ova.  The  discus  proligerus  is 
seated  sometimes  superficially,  sometimes  in  the  deepest  portion  of  the 
follicle.  Each  ovum  is  surrounded  by  a  special  layer  of  cylindrical 
epithelium  (epithelium  of  the  ovum). 

Henle  estimates  the  entire  number  of  Graafian  follicles  in  each  ovary 
at  thirty-six  thousand. 

The  primordial  ova,  we  have  seen,  consisted  originally  of  epithelial 
cells  distinguished  by  their  rounded  shape  and  large  nuclei.  For  a  cer- 
tain period  these  cells  have  a  continuous  growth,  due  probably  to  the 
absorption  of  nutritive  material  furnished  by  the  liquefaction  of  cells 
in  the  discus  proligerus.  The  nutrient  material,  according  to  Nagel,* 
is  derived  from  special  cells  containing  nuclei  and  one  or  more  nucleoli, 
and  of  larger  size  than  the  ordinary  follicular  epithelium.  The  liquefied 
product,  Nagel  maintains,  enters  the  protoplasm  of  the  primitive  ova 
by  diffusion. 

The  fully  developed  ovum  is  no  longer  a  simple  cell  composed  of  pro- 
toplasm. It  is  of  large  size.  In  the  human  female  the  ovum  measures 
about  yfg-  of  an  inch  in  diameter.  As  it  lies  in  the  discus  proligerus  it 
is  surrounded  by  elongated  cells  with  distinct  nuclei  and  finely  granu- 
lar protoplasm.  These  cells  are  placed  side  by  side,  and  are  arranged 
in  two  to  three  layers.  By  Waldeyer  they  have  been  termed  the  epithe- 
lium of  the  ovary,  and  by  Bischoff,  owing  to  their  characteristic  appear- 
ance, the  zona  radiata. 

The  mature  ovum  possesses  a  thick,  transparent  envelope,  termed 
the  vitelline  membrane  or,  from  the  manner  in  which  it  transmits  light, 
the  zona  pellucida.  The  zona  pellucida  was  formerly  thought  to  be 
due  to  a  thickening  of  the  cell  contour.  It  is  now  commonly  regarded 
as  something  superadded  to  the  primordial  ovum.  Probably  the  at- 
tached portions  of  the  radiate  cells  contribute  to  its  formation.  It  has 
been  noticed  as  a  curious  coincidence,  that  at  the  time  of  the  appear- 
ance of  the  zona  pellucida  a  similar  clear,  structureless  membrane  de- 
velops between  the  membrana  granulosa  and  the  internal  layer  of  the 
theca  folliculi.  When  the  zona  has  once  formed  around  the  ovum  the 
latter  ceases  to  increase  in  size. 

The  ovum  and  the  zona  are  not  in  immediate  contact.  Between 
the  two  there  exists  a  clear  space,  termed  the  perivitelline  space,  which 

*  W.  Nagel,  Das  Menschliche  Ei,  Arch,  fur  Microscopische  Anatomic,  vol.  xxxi, 
pp.  380  and  381.  The  ovaries  were  examined  in  a  perfectly  fresh  condition  after 
their  removal  from  the  body  for  surgical  reasons. 


2ona  pelliicida 


^''otoplasmic 

Zoncr' 


Fhife  II 


Perivitclline  Space. 


A51 


Cells  of  the  discus 
proligerus. 

Corona  radiata. 
(terminal  Vesicle, 


'  ^e^toplasmic  Zone. 


-fc^. 


J'rotoplasmic  Zone 


Cortma  radiata 


-^K: 


Zona,  pellucida. 


Deutoplasmic  Zone. 


(  \  Q-erminal  Vesicle, 
]  vjifh  an  amceboid 
"^germinal  Spot. 


Fig.  2. 


J'erivitelline  Space. 

Clear  Outer  Zone. 

Fig.  l.-Deutoplaem-forming  ovum  from  a  Graafian  follicle  of  a  woman  27  years  old  (Nagel). 
Pig.  2. -Fresh  ovum  from  Graafian  folUcle  of  a  woman  30  years  old;   slightly  reduced  from 
the  original  figure  (Nagel). 


DEVELOPMENT   OF   THE   OVUM. 


39 


permits  amwboid  movement  and  rotation  of  the  egg  protoplasm  to  take 
place.  The  thickness  of  the  zona  is  from  one  twentieth  to  one  tenth 
the  diameter  of  the  ovum. 

The  body  of  the  cell,  which  constitutes  the  primordial  ovum,  be- 
comes the  vitellus  of  the  ripe  egg.  It  possesses  contractility  and  other 
properties  of  protoplasm.  In  the  mature  ovum  it  assumes  an  opaque 
appearance,  due  to  the  development  of  granular  matter  and  light-re- 
fracting particles.  The  primitive  cell  matter  of  the  vitellus  is  termed 
the  protoplasm  of  the  ovum,  or  the  formative  yelk.  From  it  are  de- 
rived the  cells  which  furnish  the  basis  of  embryonic  development.  The 
small  particles  consist  of  nutrient  material,  and  are  termed  deutoplasm, 
or  the  7iutritive  yelk,  as  they  constitute  at  an  early  period  the  material 
which  contributes  to  the  cell  growth.  The  deutoplasm  is  supposed 
to  be  derived  from  the  liquefied  cells  of  the  discus  proligerus,  but  in 
the  human  ovum  the  penetration  of  particles  from  without  is  not 
direct.  They  do  not  appear  until  after  the  zona  is  formed,  when  the 
growth  of  the  ovum  ceases.  They  therefore  are  to  be  regarded  as  the 
product  of  the  vital  activity  of  the  cell.  Upon  the  addition  of  eosin 
the  protoplasm  is  colored  with  a  beautiful  rose  tint,  while  not  a  trace 
of  the  coloring  matter  is  taken  up  by  the  deutoplasm  (Nagel).  The 
particles  first  make  their  appearance  at  the  center  of  the  vitellus.  In 
the  perfectly  fresii  human  ovum  it  is  possible  to  distinguish  a  central 
portion  rendered  opaque  by  deutoplasm,  a  finely  granular  ring  in  which 
the  protoplasm  predominates,  and  a  clear  peripheral  border  in  which 
the  protoplasm  is  free  from  deutoplasmic  matter. 

The  nucleus  of  the  cell  becomes  converted  into  a  large,  clear,  color- 
less vesicle,  known  as  the  germinative  vesicle.  It  occupies  an  eccen- 
tric position  in  the  clear  outer  zone  of  the  vitellus.  The  nucleolus  per- 
sists as  a  dark,  probably  solid  body  within  the  germinative  vesicle.  It 
is  characterized  by  amoeboid  changes  of  shape,  and  is  termed  the  germi- 
native spot. 

Discharge  of  the  Ova  from  the  Ovary,  and  the  Formation 
OF  the  Corpus  Luteum. — We  have  already  seen  that  the  number  of 
Graafian  follicles  within  a  single  ovary  is  estimated  at  many  thousands. 
The  formation  of  these  follicles  is,  in  great  degree  at  least,  completed 
during  the  antenatal  period  of  existence.  Previous  to  puberty,  how- 
ever, they  remain  in  a  quiescent  condition.  With  the  advent  of 
puberty  the  ovaries  assume  functional  importance.  The  surface  of  the 
ovary,  if  examined  at  this  time,  is  no  longer  smooth,  but  studded  with 
small  vesicles.  These  vesicles  are  nothing  more  than  the  enlarged 
Graafian  follicles,  which,  as  they  become  distended  by  their  fluid  con- 
tents, approach  the  periphery,  thin  the  tunica  albuginea,  and  form 
rounded  translucent  prominences.  By  the  additional  disappearance  of 
the  blood-vessels  and  the  lymphatics,  a  weak  point  in  the  wall  of  the 
follicle,  the  macula  or  stigma  folUcuU,  is  left  exposed. 


^Q  PHYSIOLOGY   OF   THE   OVUM. 

The  discharge  of  the  ovum  is  closely  associated  with  the  formation 
of  the  corpus  luteum. 

The  corpus  luteum  begins  by  an  abundant  cell  proliferation,  in  which 
both  the  follicular  epithelium  and  the  tunica  propria  participate.  This 
cell  proliferation  is  most  abundant  at  the  bottom  of  the  Graafian  fol- 
licle. Vascular  arches  push  forth  into  the  cavity,  and  still  further  en- 
croach upon  the  already  crowded  space.  Finally,  a  point  is  reached  at 
which  the  follicle  ruptures,  and  its  contents,  including  the  ovum,  are 
discharged.  When  the  Graafian  follicle  has  reached  maturity,  the  con- 
gestion, occurring  at  the  time  of  the  menses,  operates  unquestionably 
in  a  most  effective  manner  to  the  accomplishment  of  this  result. 

Immediately  following  the  rupture  of  the  Graafian  follicle,  blood  is 
effused  into  its  cavity.  At  the  same  time  a  process  of  cell  disintegra- 
tion ensues.  But,  in  place  of  a  degenerative  product,  the  disintegra- 
tion furnishes  a  granular,  vitellus-like  substance  of  a  yellow  color.  Ex- 
amined by  the  microscope,  in  addition  to  the  granular  mass,  globules 
may  be  recognized,  which  correspond  to  the  light-refracting  particles 
contained  in  the  vitellus  of  the  ovum. 

While  the  above-mentioned  process  is  going  on,  an  abundant  trans- 
migration of  wandering  cells  (lutein  cells,  Nagel)  from  the  vascular 
network  surrounding  the  follicle  takes  place,  which  lift  up  the  granu- 
losa cells,  with  the  pseudo-yelk  substance,  and  press  them  toward  the 
center  of  the  follicle.  Along  with  the  young  wandering  cells,  vascular 
offshoots,  like  small  papilla?,  push  out  from  every  side  into  the  epithe- 
lial and  vitellus-like  masses.  As  the  larger  vessels  form  more  marked 
projections,  they  give  to  the  corpus  luteum  a  folded  appearance. 

In  a  state  of  complete  development  the  corpus  luteum  consists  of — 
1.  The  pseudo-yelk  substance,  mingled  Avith  effused  blood.  2.  The 
thickened  layer  of  the  granulosa  and  lutein  cells,  mingled  with  yelk- 
substance.  It  is  this  layer  which,  to  a  great  extent,  forms  the  folded, 
yellow  portion  of  the  corpus  luteum.  3.  The  vessels  which,  'with  the 
lutein  cells,  push  from  all  directions  into  the  epithelial  masses.  As 
these  vessels  reach  the  center  of  the  follicle,  a  complete  interpenetra- 
tion  of  the  connective  tissue  and  epithelial  elements  of  the  corpus 
luteum  results,  and  the  foldings  become  indistinct. 

Finally,  absorption  of  the  vitellus-like  substance  occurs;  the  last 
vestiges  of  the  effused  blood  are  converted  into  blood-crystals ;  the  arte- 
rial vessels  degenerate  ;  the  epithelial  masses  and  the  connective-tissue 
mesh-works  disappear  gradually,  until  at  the  last  only  a  white,  stellate 
cicatrix  remains. 

If  the  ovum  is  discharged  without  impregnation  taking  place,  the 
corpus  luteum  reaches  its  maximum  size  at  the  end  of  three  weeks,  and 
then  begins  to  decline,  until,  at  the  end  of  two  months,  it  is  reduced  to 
an  insignificant  cicatrix.  But  when  conception  occurs,  the  changes  in 
the  corpus  luteum  take  place  more  slowly.    The  corpus  luteum  reaches 


DEVELOPMENT  OP  THE  OVUM.  ^i 

a  higher  state  of  development.  Its  increase  in  size  continues  for  two 
months.  It  then  remains  stationary  up  to  the  end  of  the  sixth  month. 
During  the  hist  three  months  of  pregnancy  it  gradually  loses  its  bright- 
yellow  color,  grows  smaller,  but  still  measures  one  half  of  an  inch  in 
diameter  at  the  end  of  the  period  of  gestation. 

The  corpus  luteum  of  pregnancy  is  often  termed  the  true  corpus 
luteum,  to  distinguish  it  from  the  more  trivial  variety  which  is  pro- 
duced by  the  rupture  of  a  Graafian  follicle  at  a  menstrual  period,  or 
between  two  menstrual  epochs.  The  latter  has  been  termed  the  false 
corpus  luteum,  because  it  is  found  in  virgins,  and  does  not  constitute 
a  sign  of  pre-existent  pregnancy. 

The  Migration  of  the  Ovum.— The  number  of  ova  in  each  ovary 
amounts  to  many  thousands.  Only  a  small  proportion  of  them,  how- 
ever, meet  with  the  conditions  requisite  for  fruition.  It  is  probable 
that  many  ova  perish  while  still  surrounded  by  the  stroma  of  the  ovary. 
It  becomes  an  interesting  subject  of  inquiry  as  to  the  conditions  which 
ordinarily  determine  the  passage  of  the  ovum  from  the  ovary  into  the 
Fallopian  tube  of  the  corresponding  side.  It  will  not  do  to  assume,  as 
is  usual,  a  peculiar  erectility  of  the  Fallopian  tube,  which  enables  it  to 
apply  its  funnel-shaped  extremity  to  the  ovary  just  at  the  moment  of 
the  rupture  of  the  Graafian  follicle.  Setting  aside  the  inherent  im- 
probability of  the  existence  of  such  a  degree  of  intelligence  in  the  fim- 
briae as  would  lead  to  the  exact  adaptation  of  the  tube  to  the  precise 
point  at  which  the  ovum  is  to  be  discharged,  it  has  been  proved  that 
the  Fallopian  tube  possesses  none  of  the  characteristics  of  erectile  tis- 
sue. Injections  of  its  vessels  after  death  do  not  communicate  to  it  the 
slightest  change  of  form  or  place.* 

Muscular  action  has  also  been  often  invoked  to  explain  the  assumed 
manner  in  which  the  fimbriae  seize  the  ovary,  but  galvanization  of  the 
tubes,  practiced  upon  criminals  recently  executed,  produces  only  ver- 
micular contractions,  which  do  not  affect  the  position  of  the  fimbrije.f 
Indeed,  when  we  remember  the  position  of  the  Fallopian  tubes  in  the 
pelvis,  and  bear  in  mind  that  they  are  at  all  times  necessarily  subjected 
to  the  pressure  of  the  intestines,  it  becomes  difficult  to  understand  how 
they  can  execute  any  very  extended  movements. | 

*  RouGET,  Les  Organes  ftrectiles  de  la  Feinme,  Jour,  de  la  Physiol.,  t.  i,  1858, 
p.  337. 

f  Hyrtl,  Handbuch  der  topographischen  Anatomie,  Wien,  1865,  Bd.  ii,  p.  210. 

i  Henle,  Handbuch  der  Eingeweidelehre,  Braunschweig,  1866,  p.  470.  Rouget 
(vide  Organes  firectiles.  Jour,  de  la  Physiol.,  1858)  has  studied  with  great  care  the 
arrangement  of  the  muscular  fibers  situated  between  the  peritoneal  layers  of  the 
broad  ligament.  These  fibers  are  directly  continuous  with  the  delicate  external 
muscular  layer  of  the  uterus.  Certain  of  them  are  so  distributed,  according  to 
Rouget,  as  to  produce  by  their  contraction  a  direct  approximation  of  the  fimbria;  to 
the  ovary.  Henle  remarks,  by  way  of  criticism,  that  more  stress  might  be  laid  upon 
tbase  fibers  were  they  distributed  to  the  Fallopian  tubes  alone.    As,  however,  they 


^2  PHYSIOLOGY  OF   THE   OVUM. 

In  the  absence  of  dii-ect  experimental  proof,  the  suggestion  oi 
Henle  that  the  passage  of  the  ovum  into  the  Fallopian  tube  is  due  to 
the  currents  produced  in  the  serum  by  the  ciliated  epithelium,  which 
covers  both  the  external  and  internal  surfaces  of  the  fimbriae,  is,  on 
the  score  of  probability,  entitled  to  the  most  consideration.  One  of 
the  fimbriae  (fimbria  ovarica.  Fig.  13)  is,  as  we  have  already  seen,  per- 
manently attached  to  the  lower  angle  of  the  ovary.  It  is  likely  that 
the  ovum,  discharged  from  a  Graafian  follicle,  is  floated  down  by  the 
peritoneal  serum  toward  the  lower  and  outer  border  of  the  ovary,  where 
a  sufficient  current  is  present  to  insure  its  being  caught  up  and  con- 
veyed into  the  infundibulum  tuba?.  Failures  on  the  part  of  the  ovum 
to  reach  its  destination  are,  in  all  probability,  not  uncommon.  Support 
is  given  to  the  theory  of  the  importance  of  the  cili*  in  influencing  the 
migration  of  the  ovum  by  the  observation  of  Thiry,*  that  in  batrachi- 
ans,  which  have  the  oviducts  fixed  to  the  abdominal  walls,  and  situated 
at  a  distance  from  the  ovary,  during  the  rutting  period  little  pathways 
of  ciliated  epithelium  form  in  the  peritonaeum,  which  collectively  con- 
verge toward  the  openings  of  the  tubes. 

Cases  of  the  complete  migration  of  the  ovum  from  the  ovary  of  one 
side  to  the  Fallopian  tube  of  the  opposite  side  are  not  readily  explained 
by  any  hypothesis.  'Yet  the  occurrence  of  such  cases  is  undoubted. 
Pregnancy,  for  instance,  may  exist  where  there  is  complete  absence  or 
closure  of  the  Fallopian  tube  upon  the  same  side  with  the  corpus 
luteum.  Leopold  tied  the  right  Fallopian  tube  in  rabbits  in  two  places, 
and  exsected  a  portion  of  the  tube  between  the  ligatures ;  the  left  ovary 
was  carefully  removed  and  the  abdominal  wound  was  closed.  After 
recovery  the  rabbit  was  put  to  the  male.  In  two  such  cases  pregnancy 
followed,  f 

The  progression  of  the  ovum  through  the  Fallopian  tube  is  effected 
by  the  ciirrent  produced  by  the  ciliated  epithelium  and  by  the  peristal- 
tic action  of  the  circular  muscular  fibers. 

Fecundation. — The  precise  point  at  which  fecundation  takes  place 
has  been  variously  assigned  by  authors  to  the  tubes,  the  uterus,  and  the 
ovary.  The  question,  however,  up  to  the  present  time  is  a  purely 
speculative  one.  The  length  of  time  required  by  the  human  ovum  to 
complete  the  passage  from  the  ovary  to  the  uterine  cavity  is  unknown ; 
nor  has  as  yet  the  period  of  the  extra-ovarian  life  of  the  ovum,  when 
not  vivified  by  the  contact  of  the  male  element  of  generation,  been  de- 
termined. Single  observations  show  that  fecundation  may  take  place 
in  any  part  of  the  course  described.  The  ordinary  site  of  fecundation 
is  a  matter  which  remains  to  be  decided  by  future  investigations. 

spread  likewise  over  the  ovary,  their  probable  action  would  consist  in  drawing  both 
ovary  and  tube  toward  the  median  line. 

*  Thiry,  Gottingen  Nachrichten,  1862,  p.  171. 

f  Arch.  f.  Gynaek.,  vol.  xvi,  p.  24. 


DEVELOPMENT   OF   THE   OVUM. 


43 


Fig.  31. — Spermatozoa  from  the  human 
subject  (magnified  eight  hundred 
diameters).    (Luschka.) 


The  seme}i,  contact  with  which  is  essential  to  the  fecundation  of 
the  ovum,  is  a  tliick,  viscid,  albuminous  fluid,  of  a  whitish  color  and 
a  peculiar  odoi-,  which  has  been  compared  to  that  of  the  raspings  of 
bone.  When  examined  by  the  microscope,  it  is  found  to  contain 
numerous  minute  anatomical  elements, 
termed  spermatozoa.  Each  spermato- 
zoon consists  of  an  oval  head  and  a  long 
filiform  extremity  or  tail.  The  head  is 
flattened,  and  measures  about  ^nsW  of 
an  inch  in  width.  When  seen  in  pro- 
file, it  presents  a  pyriform  appearance. 
The  entire  spermatozoon  measures  from 
^oTT  ^o  T^  ^^  ^^  inch  in  length. 

The  spermatozoa  do  not  simply  float 
in  the  seminal  fluid,  but  possess  the 
capacity  of  moving  from  place  to  place, 
as  though  endowed  with  volition.  In- 
deed, as  the  observer  sees  them  advance,  now  singly  and  now  in  shoals, 
now  diving  down  and  then  rising  again  to  the  surface,  now  avoiding 
some  obstacle,  or  skillfully  picking  their  way  between  masses  of  epi- 
thelium, it  is  difficult  to  resist  the  conviction  that  they  are  really,  what 
they  were  long  supposed  to  be,  distinct  organisms  capable  of  a  certain 
degree  of  voluntary  action.  But  there  is  little  doubt,  at  the  present 
day,  that  the  undulatory  movements  of  the  tail,  which  furnish  the  pro- 
pelling force,  are  due  to  purely  molecular  tissue  changes,  similar  to 
those  which  give  rise  to  the  amoeboid  movements  of  protoplasm  or 
the  oscillations  of  the  hair-like  processes  of  ciliated  epithelium. 

Henle  estimates  that  the  spermatozoa  travel  at  the  rate  of  an  inch 
in  seven  and  a  half  minutes.  It  is  to  these  bodies  that  the  semen  owes 
its  fecundating  power,  but  only  so  long  as  they  retain  the  faculty  of 
motion — a  faculty  which  has  been  found  to  exist  in  full  force,  within 
the  female  genital  organs,  eight  to  ten  days  after  ejaculation.* 

In  1840  Martin  Barry  described  a  point  in  the  zona  pellucida  (vitel- 
line membrane)  of  the  rabbit,  which  appeared  to  him  to  be  an  opening 
designed  for  the  passage  of  spermatozoa.  At  first  embryologists  pro- 
nounced Barry's  descriptions  to  be  based  upon  an  illusion,  but  since 
then  the  existence  of  such  an  opening,  termed  later  by  Keber  the  mi- 
cropyle,  has  been  abundantly  demonstrated  in  the  ova  of  fishes,  mol- 
lusks,  insects,  etc.f 

A  very  interesting  series  of  observations  connected  with  this  sub- 
ject have  been  made  by  M.  Kobin  upon  the  ova  of  the  nephelis  vul- 
garis, or  common  leech.     The  earliest  token  of  the  maturity  of  the 

*  Luschka,  Die  Anatomie  des  menschlichen  Beckens,  Tubingen,  1864,  p.  273. 
t  Vide  Milne-Edwards,  Legons  de  la  Physiologie,  t.  viii,  Paris,  1873,  pp.  361  et 
seq. ;  Waldeyer,  Eierstock  und  Nebeneierstock,  Stricker's  Handbuch,  p.  354. 


4:4 


PHYSIOLOGY  OF  THE  OVUM. 


ovum  consisted  in  the  disappearance  of  the  germinative  vesicle.  At  the 
same  time  a  retraction  took  place  in  the  vitellus,  which  became  thereby 
reduced  one  sixth  to  one  fourth  in  size.  At  first  the  removal  of  inter- 
nal pressure,  consequent  upon  this  retraction,  led  to  a  wrinkling  of  the 
vitelline  membrane.  Afterward,  however,  a  clear,  limpid  fluid,  proba- 
bly in  part  exuded  from  the  vitellus  and  in  part  derived  by  endosmosis 
from  external  sources,  filled  up  the  intervening  space,  and  caused  the 
wrinkles  to  disappear.  The  spermatozoa,  in  their  movements  around 
the  ovum,  assumed  a  perpendicular  or  oblique  direction  to  the  vitelline 
membrane.     At  one  point  in  the  membrane  the  penetration  of  these 

bodies  could  be  distinctly  observed. 
At  the  end  of  an  hour  the  penetra- 
tion had  ceased,  and  then  a  little 
bundle  of  spermatozoa  could  be  seen 
arrested,  partly  within  and  partly 
without  the  ovum.  In  the  clear, 
limpid  space  surrounding  the  vitel- 
lus, the  spermatozoa  continued  to 
move  about  actively  for  a  time,  but 
in  fifteen  to  twenty  minutes  their 
movements  began  to  grow  slow,  and 
in  a  couple  of  hours  had  ended 
altogether.* 

In  the  human  ovum  nothing  in 
the  nature  of  a  micropyle  has  been 
observed.  The  fine  radiate  lines  which  may  be  seen  in  the  zona 
pellucida  when  high  magnifying  powers  are  employed  do  indeed 
suggest  the  idea  of  minute  pores,  but  the  view  of  Waldeyer  f  has 
been  generally  accepted,  that  these  are  really  unchanged  filaments  of 
protoplasm  derived  from  the  cells  to  which  the  zona  pellucida  owes 
its  origin. 


Fig.  32.— Ovum  of  the  nephelis  vulgaris, 
showing  retraction  of  vitellus  and  the 
penetration  of  the  spermatozoa  through 
the  vitelline  membrane  (magnified  three 
Ijundred  diameters).    (Robin.) 


Changes  taking   place  in  the  Ovum   subsequent  to   Fecun- 
dation. 

In  describing  its  anatomy,  we  have  noted  that  the  ovum  was  orig- 
inally a  simple  cell,  possessing  contractility  and  other  properties  of  liv- 
ing matter.  The  ova  of  certain  of  the  sponges,  which  do  not  possess 
a  zona  pellucida,  move  about  under  the  field  of  the  microscope  by 
pushing  out  finger-like  processes,  precisely  like  the  ordinary  amoeba.J 
Contractile  movements  of  the  vitellus  within  the  zona  pellucida  have 

*  Memoire  sur  les  Phenoraenes  qui  se  passent  dans  I'Ovule  avant  la  Segmenta- 
tion du  Vitellus,  Robin,  Jour,  de  la  Physiol.,  t.  v,  pp.  67  et  seq. 

\  Waldeyer,  Eierstock  und  Nebeneierstock,  Strickee's  Handbuch  der  Lehre 
von  den  Geweben,  Leipsic,  1871,  p.  354. 

X  Haeckel,  Anthropogenie,  Leipsic,  1874.  p.  112. 


DEVELOPMENT   OF  THE  OVUM.  45 

been  described  by  Robin  in  the  ova  of  the  leech  and  other  low  orders 
of  animal  life.* 

With  the  formation  of  the  deutoplasm  the  germinative  vesicle  is 
crowded  to  the  periphery  of  the  ovum. 

The  maturity  of  the  ovum  is  signalized  by  the  detachment  from 
the  main  mass  of  two  small  cells  termed  the  polar  globules.  Formerly 
this  process  was  supposed  to  be  associated  with  the  disappearance  of 
the  germinal  vesicle.  More  recent  investigations  have  demonstrated 
that  in  the  production  of  the  polar  globules  the  germinative  vesicle 
plays  an  active  part.  Thus  observation  shows  that  the  latter  elongates 
in  a  radiate  direction.  Around  the  two  extremities,  or  poles,  nuclear 
matter  from  the  vitellus  collects.  A  separation  of  the  lines  connectino- 
the  poles  next  takes  place,  and  two  new  nuclei  surrounded  by  radiate 
masses  of  yelk  matter  result.  These  liave  a  star-like  arrangement. 
The  upper  pole  is  then  extruded  and  the  first  polar  globule  is  formed. 
The  process  is  then  repeated,  and  the  second  polar  globule  is  perfected. 
Finally  the  persistent  portion  of  the  original  nucleus  recedes  from  the 
surface.  It  resembles  in  appearance  the  original  germinal  vesicle  with 
its  nucleolus,  and  is  known  as  i\\&  female  pronucleus. 

The  formation  of  the  polar  globules  is  a  sign  that  the  ovum  has 
reached  maturity,  and  occurs  independently  of  fecundation.  The  latter 
is  effected  by  the  penetration  into  the  vitellus  of  a  single  spermatozoon, 
the  head  of  which  is  termed  the  )nale  pronudeus.  The  male  pro- 
nucleus approaches  the  female  pronucleus,  and  the  two  coalesce  to 
form  the  segmentation  nucleus  of  the  fecundated  ovum.  After  this 
union  has  taken  place  the  ovum  is  turmed  the  oosperm. 


F.PNr^ 

'.     ...  \~M.PN. 

F.PNr 


Fig.  33 —Fertilization  of  ovum  of  a  mollusk  (Elysici  viridis).  A,  ovum  sending  up  a  protuber- 
ance to  meet  the  spermatozoon.  B.  approach  of  male  pronucleus  to  meet  the  female  pro- 
nucleus.   F.  PN,  female  pronucleus  ;  M.  PN,  male  pronucleus  ;  S,  spermatozoon. 

Almost  immediately  after  the  production  of  the  segmentation  nucleus 
it  divides  into  two  nuclei.  By  a  similar  process  of  cleavage  the  vitellus 
likewise  divides  into  two  halves.  The  nuclei  act  as  central  points, 
around  which  collect  the  molecular  and  viscid  portions  of  the  pro- 
toplasm. In  this  manner  the  ovum  is  divided  into  two  new  cells,  which 
differ  somewhat  in  size,  and  which  lie  near  together  within  the  zona 

*  Haeckel,  Anthropogenie,  Leipsic,  1874,  pp.  100  et  aeq. 


4:6 


PHYSIOLOGY   OP   THE   OVUM. 


pellucida.  The  larger  cell  and  tliose  subsequently  derived  from  it  are 
termed  the  epiblastic  spheres,  and  the  smaller  one  with  its  products 
are  termed  hypoblastic  spheres.  To  the  cleavage  process  by  which  the 
single  cell  has  been  converted  into  two,  the  term  segmentation  is 
applied.  By  continued  segmentation  the  two  cells  are  divided  into 
four,  the  four  into  eight,  and  so  in  succession,  until   finally  a  great 


Fig.  34.— Formation  of  the  blastodermic  vesicle  (Van  Beneden).  A,  B,  C,  D,  sections  of  ova  in 
successive  stages  of  development  in  the  rabbit ;  zp,  zona  pellucida  ;  ep,  epiblastic  cells  ; 
hyp,  hypoblastic  cells. 

multitude  are  generated,  all  closely  crowded  together,  and  giving  to 
the  ovum  a  mulberry  appearance ;  whence  the  term  morula  has  been 
applied  to  the  ovum  at  this  stage  of  its  development. 

"When  the  segmentation  process  is  completed,  the  epiblast  cells 
occupy  the  outer  circumference  and  line  the  inner  surface  of  the  zona 
pellucida,  except  at  one  point,  termed  by  Van  Beneden  the  blastophore. 
They  are  clear,  and  have  an  irregular  cubical  form.  The  hypoblast 
cells  form  a  solid  mass  in  the  center.  They  are  granular,  polygonal, 
and  are  somewhat  larger  than  the  epiblast  cells. 

The  epiblast  cells  next  grow  over  the  blastophore.     A  layer  of  fluid 


DEVELOPMENT   OP   THE   OVUM. 


47 


Fio.  35.  —  Diagrammatic  sec- 
tion (Haddon)  of  mamma- 
lian blastoderm  after  the 
cover-cells  have  closed  in 
the  blastoderm,  and  the 
embryo  proper  has  become 
two-layered.  ep\  non-em- 
bryonic epiblast ;  ep,  em- 
bryonic epiblast ;  hy,  hypo- 
blast ;  y.  s,  yelk  .sac. 


then  forms  within  the  morula,  by  means  of  wliich  the  epiblast  and 
hypoblast  cells  are  separated  from  one  another  except  at  the  point 
where  the  blastophore  had  previously  existed. 
By  an  increase  of  the  fluid  the  morula  is 
converted  into  a  globular  vesicle,  termed  the 
blastodermic  vesicle.  The  hypoblast  cells  are 
pressed  to  the  circumference,  where  they  form 
a  lens-shaped  mass  attached  to  the  epiblast 
cells  and  projecting  into  the  cavity  of  the 
vesicle.  The  blastodermic  vesicle  continues 
to  enlarge  rapidly.  The  hypoblast  cells  be- 
come flattened  and  spread  over  the  inner  sur- 
face of  the  epiblast.  The  central  part  thick- 
ens and  forms  a  dark  spot,  which  constitutes 
the  commencement  of  the  embryonic  area; 

upon  sec- 
tion, the 
embryonic 

area  is  found  to  consist  of  three  lay- 
ers, the  outer  layer  composed  of  epi- 
blast cells,  and  two  inner  layers  com- 
posed of  hypoblast  cells.  The  former 
takes  no  active  part  in  the  formation 
of  the  embryo,  but  disappears  at  an 
early  period.  Beyond  the  embryonic 
area  the  epiblast  cells  help  to  form  the 
amnion.  The  hypoblast  cells  alone 
contribute  to  the  formation  of  the 
new  being.  The  outer  layer  becomes 
the  epiblast,  and  the  inner  layer  forms 
the  hypoblast  of  the  embryo.  Sub- 
sequently a  third  intermediate  cell 
layer,  termed  the  mesoblast,  develops 
between  the  embryonic  epiblast  and 
hypoblast.  At  a  later  period  the  cells 
of  the  mesoblast  and  of  the  hypoblast 
spread  by  peripheral  extension,  and 
finally  line  the  inner  surface  of  the 
primitive  epiblast.* 
Without  entering  minutely  into  the  subject,  it  may  be  well  to  state 
that,  according  to  present  views,  the  three  layers  existing  at  the  em- 

*  This  description  is  taken  from  Van  Beneden's  Developperaent  Embryonnaire 
des  Mamraiferes,  Bull,  de  I'Acad.  Belgique,  1874.  Vide  translation  in  article  The 
Physiology  and  Histology  of  Ovulation,  Menstruation,  and  Fertilization,  etc.,  by 
Newell  Martin,  Hirst's  System  of  Obstetrics,  vol.  i,  p.  101. 


Fig.  36.— Surface  view  of  area  pellucida  of 
hen's  egg,  after  eighteen  hours  of  incu- 
bation (Balfour).  A,  medullary  folds  ; 
m.c,  medullary  groove  ;  pr,  primitive 
groove. 


48 


PHYSIOLOGY  OF  THE  OVUM. 


bryonic  area  are  assumed  to  liave  the  following 
relations  to  the  ulterior  development  of  the  body : 

The  epiblast  is  concerned  in  the  formation  of 
the  epidermis,  hair,  nails,  the  epithelium  of  the 
mouth,  nose,  and  of  the  cloaca,  the  glandular 
structures  of  the  skin,  the  brain,  the  spinal  cord, 
and  the  organs  of  special  sense. 

The  hypoblast  furnishes  the  epithelium  lining 
the  walls  and  glands  of  the  intestines,  and  the  epi- 
thelium of  the  lungs  and  of  the  air  passages. 

The  mesoblast  gives  rise  to  the  corium,  the 
muscles  of  the  trunk,  the  bony  framework,  the 
connective  tissues,  the  muscular  structures  of  the 
digestive  tracts,  the  blood,  the  blood-vessels,  and 
the  genito-urinary  system.* 

The  first  change  observed  in  the  embryonic 
area  consists  in  the  appearance  of  a  dark  streak, 
the  primitive  streak,  due  to  a  thickening  of  the 
mesoblast.  It  becomes  grooved,  and  is  known  as 
the  primitive  groove.  It  has  nothing  to  do  with 
the  development  of  the  embryo.  The  embryonic  area,  which  was  pre- 
viously of  a  rounded  form,  now  assumes  an  ovoid  shape.     In  front  of 

d  f  m  h 


a.pr- 


P.pr- 


Fig.  37. — Dorsal  view  of 
embryonic  area  of 
blastoderm  of  chick 
after  the  medullary 
folds  have  arched 
over  and  met  for  t 
great  part  of  their 
extent  but  have  not 
j-et  fused  together, 
a.  pr,  anterior  part 
of  primitive  groove  ; 
p.  pr,  remnant  ol 
posterior  part  of 
primitive  groove. 


Fia.  38.— Transverse  section  through  the  eniliryo  of  the  chick  a  few  hours  after  the  commence- 
ment of  incubation,  h,  epiblast ;  ?/i,  external  stratum  of  mesoblast ;  /,  internal  stratum  of 
mesoblast ;  d,  hypoblast ;  n,  medullary  groove  ;  x,  chorda  doraalls. 


the  primitive  trace  two  ridges  are  formed  by  a  thickening  of  the  epi- 
blast.    These  ridges  are  known  as  the  medullary  folds.     They  bound 

a  furrow  termed  the  medullary 
groove.  The  folds  at  first  diverge 
behind,  but  soon  converge  and 
meet  so  as  to  include  between 
them  the  front  portion  of  the 
primitive  trace. 

Upon    microscopic    examina- 
tion of  a  t>ransverse  section  at 


Fig.  39.— Diagram  representing  transverse  sec- 
tion through  the  embryo  of  a  chick  at  the 
end  of  the  first  day  of  incubation,  m,  me- 
dullary plates  ;  c/i,  chorda  dorsalis  ;  v,  ver- 
tebral chords  ;  a  p,  abdominal  plates. 


*  Haeckel,  Anthropogenie,  p.  218.  According  to  His,  the  three  primitive  lay- 
ers are  concerned  in  the  formation  of  the  epithelial,  the  muscular,  and  the  nerve 
tissues  only,  whereas  the  blood  and  connective  tissues,  comprising  the  leucocytes, 
the  red  blood-corpuscles,  the  blood-glands,  the  endothelia,  and  all  the  connective- 


DEVELOPMENT   OP  THE   OVUM.  49 

this  time  the  three  layers  of  the  embryo  are  found  in  tlie  vertebrata 
to  be  united  at  the  median  line.     The  intermediate  layer  (mesoblast), 


f'Tt\y 


Fio.  40.— Transverse  section  through  the  enibiyo  of  a  chick  on  the  second  day  of  incubation. 
(Magnified  one  hundred  diameters),  t  m.  the  dorsal  plates  have  closed  to  form  tubus  medul- 
lar is  ;  the  connection  with  the  outer  or  cutaneous  layer  (ci  is  broken  off  ;  ch,  chorda  ;  v, 
vertebral  chords  ;  (i  /»,  the  abdominal  plates,  have  separated  into  an  external  and  internal 
stratum,  united  at  in  to  form  the  mesenteric  folds. 


which  possesses  the  greatest  thickness,  already  presents  the  appearance 
of  two  closely  connected  strata.  The  medullary  groove  may  be  recog- 
nized in  the  middle  of  the  upper 
surface,  and  the  dorsal  plates  are 
seen  rising  up  as  low  ridges. 
At  the  same  time,  just  beneath 
the  furrow,  a  cylindrical  organ, 
known  as  the  chorda  dorsali.'<, 
becomes  separated  from  the  cell- 
mass.  The  chorda  dorsal  is  owes 
its  importance  to  the  fact  that 
it  is  around  this  cylindrical  body 
that  the  vertebra  subsequently 
form.  Tlie  vertebrae  themselves 
are  derived  from  two  longitudi- 
nal chords,  separated  by  a  cleav- 
age from  the  portions  of  the  in- 
termediate layer  next  to  either 
side  of  the  chorda  dorsalis.  The 
peripheral  portions  of  the  inter- 
mediate layer  are  now  termed 
the  lateral  or  abdominal  plates. 
Meantime  the  medullary  folds 
continue  to  grow,  and,  by  curv- 
ing toward  one  another,  finally 
meet  in  the  median  line,  so  as  to 


Fio.  41.— Section  through  the  ovum  of  chick 
after  development  of  umbilical  vesicle,  c  /i, 
chorda  dorsalis  ;  t  m,  tuba  meduUaris  ;  om, 
outer  layer  of  mesoblast,  from  which  are 
formed  the  bony  skeleton,  the  blood-vessels, 
and  large  muscles  of  the  trunk  ;  ect,  epi- 
blast ;  int.  intestinal  tube,  formed  from  the 
inner  stratum  of  the  mesoblast  and  the  hy- 
poblast (en() :  u  I',  umbilical  vesicle,  con- 
tinuous with  intestine ;  a  p.  abdominal 
plates,  formed  from  the  outer  stratum  of 
the  mesoblast  and  the  hypoblast.  Event- 
iiallj-  the  abdominal  plates  meet  to  inclose 
the  cavity  of  the  trunk  (.thorax  and  abdo- 
men) ;  am,  amnion,  formed  from  epiblast 
and  outer  stratum  of  the  mesoblast ;  z.  zona 
pellucida  ;  ?,  outer  lamina  of  the  amniotic 
folds,  derived  from  the  primitive  epiblast. 


tissue  forms,  including  cartilage,  bone,  and  teeth,  are  derived  from  cell  elements 
outside  the  area  germinativa  into  which  they  subsequently  migrate  and  especially 
invade  the  median  layer.  The  three  primary  layers  His  terms  the  archiblast,  and 
the  invading  cells  the  parablast.  The  median  layer  is,  to  a  great  extent,  a  second- 
ary formation.  For  an  excellent  discussion  as  to  the  origin  of  the  parablast,  the 
curious  reader  is  referred  to  Archiblast  and  Parablast,  Waldeyer,  Bonn,  1883. 


5Q  PHYSIOLOGY   OF  THE   OVUM. 

form  a  closed  tube,  the  tubus  meduUaris,  in  which  is  developed  the 
central  nervous  system.  Tims  it  Avill  be  noticed  that  the  organ 
through  the  agency  of  which  the  individual  is  brought  into  contact 
with  the  external  world  is  primitively  derived  from  the  epiblastic  layer. 

The  intermediate  layer  (mesoblast)  now  separates  into  an  internal 
and  external  stratum,  the  existence  of  which,  it  has  been  noted,  was 
indicated  at  an  earlier  stage.  These  two  strata  remain  united  by  their 
inner  borders,  and  form  later,  at  the  point  of  union,  the  mesenteric 
folds.  The  outer  extremities  of  the  inner  of  these  strata  now  curve 
inward,  and  finally  unite  together  to  form  the  intestine.  They  inclose 
at  the  same  time  the  hypoblast.  The  closure,  unlike  that  of  the  dorsal 
plates,  takes  place  from  front  to  rear,  as  well  as  from  the  two  sides. 
The  intestinal  tube  is  thus  formed  from  the  inner  stratum  of  the 
mesoblast,  which  furnishes  the  fibro-muscular  tissues,  and  from  the 
hypoblast,  from  which  the  glandular  structures  are  derived.  A  por- 
tion of  the  blastodermic  vesicle  is,  however,  not  included  in  the  in- 
testinal tube,  but  hangs,  during  the  early  months  of  gestation,  from 
the  body  of  the  embryo,  and  is  termed  the  umhilical  vesicle  {u  v). 
Finally,  the  epiblast  and  the- outer  stratum  of  the  mesoblast  (the  fibro- 
muscular  layer  of  the  trunk)  curve  forward  and  inward  so  as  tc 
inclose  a  long  cavity  which  surrounds  the  intestine.  This  cavity  in 
mammals  subsequently  becomes  divided  by  the  diaphragm  into  thorax 
and  abdomen. 

The  body  of  the  embryo,  seen  in  profile,  at  the  time  these  changes 
are  going  on,  possesses  a  thickened  anterior  or  cephalic  portion  and  a 
tapering  posterior  extremity.  It  manifests  at  an  early  2)eriod  a  tend- 
ency to  elevate  itself  above  the  level  of  the  area  germinativa.  The 
back  becomes  arched,  and  the  extremities  approximate  toward  one 
another.  Fluid  collects  between  the  two  strata  of  the  mesoblast  and 
separates  them  from  one  another.  Of  these,  the  outer  stratum  forms  a 
union  with  the  primitive  epiblast  so  as  to  produce  a  single  membrane, 
folds  of  which  rise  at  the  same  time  from  the  extremities  and  sides 
of  the  embryo,  and  encompass  it  with  an  outer  wall  or  parapet.  In 
the  process  of  growth  these  folds  approach  one  another  over  the  dor- 
sum of  the  embryo,  and  finally  unite  together.  Thus  a  sac,  including 
the  embryo,  is  formed,  termed  the  amnion,  the  cavity  of  which  sub- 
sequently fills  with  fluid. 

Nourishment  of  the  Embryo. 

It  now  becomes  a  matter  of  importance  for  us  to  consider  the 
sources  from  which  the  embryo  receives  the  nutritive  materials  requi- 
site for  its  further  growth  and  development. 

The  ovum,  in  its  passage  through  the  Fallopian  tube,  is  increased 
in  size  by  absorption  of  albuminous  materials  from  -^  of  an  inch  to 
from  -^  to  ^  of  an  inch. 


DEVELOPMENT   OF   THE   OVUM. 


51 


a:  a! 


Fig.  42.— Diagram  showing  early 
stage  in  development  of  amuion. 
a,  <(,  epiblast,  rising  ujj  over  the 
dorsum  of  enibrj-o  to  form  the 
amniotic  folds  ;  p,  allantois  ;  m, 
umbilical  vesicle. 


In  describing  the  formation  of  the  intestinal  tube,  it  was  noted  that 
a  portion  only  of  the  blastodermic  vesicle  was  included  by  the  curving 
inward  of  the  inner  stratum  of  the  mesoblast,  while  a  portion,  known 
as  the  umbilical  vesicle,  hung  from  the  abdomen.  The  umbilical  vesicle 
is  lined,  like  the  intestinal  tube,  by  the  hypoblast,  and  is  covered  by  an 
extension  of  the  inner  stratum  of  the 
mesoblast.  At  first  the  cavity  of  the 
vesicle  communicates  with  the  intestine. 
Vessels  from  the  intestinal  tube  are  dis- 
tributed over  its  surface,  through  the 
medium  of  which  it  contributes  to  the 
nourishment  of  the  embryo.  This  ar- 
rangement, however,  is  only  temporary. 
The  passage  very  soon  becomes  obliter- 
ated, and  the  remains  of  the  uml)ilical 
vesicle  hang  downward,  attached  by  an 
impervious  pedicle  to  the  intestine. 

From  the  time  the  ovum  has  passed 
into  the  uterus,  however,  it  derives  its 
main  nutritive  supply  from  the  mucous 

membrane  of  that  organ,  at  first  by  simple  absorption,  and  afterward 
by  the  formation  of  the  placenta,  an  organ  through  which  the  blood  of 
the  foetus  circulates,  separated  from  that  of  the  mother  by  the  thinnest 

of  partitions.  Through  the  party- 
wall  there  pass  to  the  foetus  all  the 
materials  necessary  for  existence 
and  growth,  and  from  the  foetus 
the  excrementitious  principles  rep- 
resenting the  waste  which  is  inci- 
dent to  vital  action. 

There  is  nothing  in  j^hysiology 
more  interesting  than  the  process 
by  which  the  circulation  of  the 
foetus  is  brought  into  close  rela- 
tion Avitli  that  of  the  mother.  It 
includes  the  consideration  of  the 
allantois,  the  cliorion,  the  dccidita, 
and  finally  the  joint  product  of 
them  all,  viz.,  the  placenta. 

The  Allantois  and  Cliorion. — 
The  chorion  is  the  external  mem- 
brane that  invests  the  ovum.  Before  the  formation  of  the  amnion  it  con- 
sists simply  of  the  zona  pellucida  or  vitelline  membrane.  As  the  ovum 
is  received  into  the  uterus  the  vitelline  membrane  becomes  covered  with 
amorphous  villi,  which  help  to  fix  the  ovum  in  the  uterine  cavit}^ 


Fig.  43.— Diagram  showing  completion  of  the 
amnion  and  formation  of  the  chorion. 
A,  amnion  ;  1  zona  pellucida  ;  2,  outer 
lamina  of  the  epiblast  after  closure  of 
amniotic  folds  ;  P,  allantois  ;  U,  umbiUcal 
vesicle. 


52 


PHYSIOLOGY   OF  THE  OVUM. 


Fig.  44.— Human  embryo  at  the  third  week,  showing 
villi  covering  the  entire  chorion.    (Haeckel.) 


After  the  completion  of  the  amniou  by  the  closure  of  the  amniotic 
folds  it  remains  for  a  time  attached  to  the  outer  lamina  of  the  epiblast, 

at  the  point  where  the  folds 
meet  over  the  back  of  the 
embryo.  The  outer  lamina 
meantime  expands  until  it 
comes  in  contact  with  the 
vitelline  membrane,  which 
then  disappears.  Thus  the 
outer  lamina  becomes  in  turn 
the  external  covering  or 
chorion.  The  new  chorion, 
like  the  one  it  superseded,  is 
speedily  covered  by  a  growth 
of  non  -  vascular  villosities. 
These  villosities  are  not 
solid,  but  hollow,  like  the 
finger  of  a  glove.  They  soon 
reach  an  extraordinary  de- 
velopment. New  villi  sprout 
upward  from  the  chorion, 
the  older  ones  push  out  buds  and  lateral  ofEshoots,  so  that  already  in 
the  third  week  the  entire  surface  of  the  ovum  is  covered  with  a  dense 
forest  of  villi,  presenting  the  most  delicate  and  graceful  characters. 

We  have  just  noted  that  the  um- 
bilical vesicle  was  a  temporary  struct- 
ure, and  only  for  a  brief  period  of 
physiological  importance.  Mean- 
time a  new  organ  is  developed,  by 
means  of  which  a  vascular  connec- 
tion is  established  between  the  em- 
bryo and  the  villi  of  the  chorion. 
This  organ  is  termed  the  allantois. 
The  allantois  begins  as  a  sac-like  pro- 
jection from  the  posterior  extremity 
of  the  intestine  at  the  time  when  the 
amniotic  folds  rise  up  in  the  form 
of  an  embankment  around  the  em- 
bryo {vide  Fig.  43).  At  this  time 
the  umbilical  vesicle  is  still  very 
large.  The  allantois,  like  the  umbilical  vesicle-  and  the  intestine,  is 
composed  of  two  layers  derived  respectively  from  the  hypoblast  and 
the  inner  stratum  of  the  mesoblast.  It  speedily  becomes  vascular,  and 
increases  rapidly  in  size.  The  inner  surfaces  of  the  sac  soon  adhere 
together,  so  as  to  form  a  single  membrane.     In  the  course  of  the  third 


FiQ.  45.— 1,  exochorion  ;  2,  endochorion  ;  C7, 
umbilical  vesicle  ;  Ay  amnion  ;  P,  pedi- 
cle of  allantois. 


PlaU  III 


Fig.  l.-Human  embryon,  at  the  ninth  week,  removed  from  the  membranes;  three  thnes 

the  natural  size  (Erdl).  .  , 

Fig.  2.-Human  embryon,  at  the  twelfth  week,  inclosed  in  the  amnion;  natural  size  (Lrdl). 


DEVELOPMENT   OF   THE   OVUM.  53 

week  the  allantois  reaches  the  chorion,  over  which  it  spreads  and  forms 
a  complete  vascular  lining.  According  to  the  usual  acceptation,  the 
vessels  of  the  allantois  everywhere  penetrate  into  the  villi  of  the 
chorion.  Then  the  chorion  and  allantois  fuse  together,  and  form  by 
their  consolidation  a  compound  membrane  termed  the  permanent 
cliurio)i.*  At  first  the  embryo  is  connected  with  the  vascular  chorion 
by  two  arteries  and  two  veins.  The  two  arteries  persist  as  the  arteries 
of  the  umbilical  cord.  One  of  the  two  veins  disappears,  while  the 
other  becomes  enlarged  in  proportion,  and  forms  the  umbilical  vein. 

With  the  growth  of  the  ovum  its  surface  diminishes  in  vascularity, 
except  in  the  neighborhood  of  the  attachment  of  the  allantoic  vessels, 
at  which  point  the  villi  increase  in  size  and  profusion.  Over  the  rest 
of  the  ovum  the  villi  atrophy  and  disappear.  Thus  the  greater  por- 
tion of  the  chorion  becomes  smooth,  while  about  one  third  of  its  sur- 
face is  covered  with  a  thickened,  shaggy  portion,  destined  to  contribute 
to  the  formation  of  the  placenta. 

The  DeciduSB. — When  the  ovum  passes  from  the  Fallopian  tubes  into 
the  uterus,  it  tinds  the  mucous  membrane  prepared,  by  certain  changes, 
for  its  reception.  These  changes,  as  shown  in  a  specimen  examined  by 
Dr.  Engelmann,f  in  the  first  month  consisted  of  a  tenfold  increase  in 
thickness  (two  fifths  of  an  inch).  The  tissues  were  intensely  vascular, 
and  the  entire  mucous  membrane  was  thrown  into  convolutions.  The 
thickening  was  mainly  due  to  an 
increase  in  the  elements  compos- 
ing the  interglandular  connective 
tissue.  This  was  more  especially 
the  case  in  the  upper  layers,  where 
the  cells  were  like  those  of  young 

connective    tissue.       A  soft,  pulpy  Fig.  46.-Formatii>n  of  deoldua,  first  stage. 

state  of  the  mucous   membrane 

was  occasioned  by  an  augmented  production  of  the  amorphous  inter- 
cellular substance  which  characterizes  connective  tissue  in  the  embry- 
onic state. 

It  is  this  thickened,  vascular,  softened  mucous  membrane  which 
furnishes  the  decidua  vera. 

The  ovum,  soon  after  its  entry  into  the  uterus,  finds  a  lodgment  in 
one  of  the  folds  of  the  decidua  vera.  This  takes  place  usually  in  the 
upper  portion  of  the  uterine  cavity,  upon  the  posterior  wall,  near  one 
of  the  tubal  orifices. 

The  point  of  attachment  between  the  ovum  and  the  decidua  is  dis- 

*  The  outer  portion,  derived  from  the  epiblast,  furnishes  the  epithelium,  and  is 
called  the  exochorion,  while  the  inner  vascular  surface  furnished  by  the  allantois  is 
entitled  the  endochorion. 

f  Engelmann,  Mucous  Membrane  of  the  Uterus,  Anier.  Jour,  of  Obstet,  May, 
1875. 


54 


PHYSIOLOGY   OP  THE   OVUM. 


Fig.  47 


—Formation  of  decidua  completed,    a,  decidua  re- 
flexa  ;  6,  decidua  vera  ;  v,  decidua  serotina. 


tinguished  as  the  deciihia  serotina.     It  is  physiologically  important  as 
the  site  of  the  placenta. 

The  ovum  is  not  simply  adherent.     It  lies,  as  it  were,  imbedded  in 
the  tumefied  membrane,  folds  of  which  grow  up  around  it,  and  finally 

meet  so  as    to    inclose 
c  it    in    a   cavity    of    its 

own,  shut  oft"  from  the 
general  cavity  of  the 
uterus.* 

The  folds  of  mucous 
membrane  wliich  inclose 
tlie  ovum  are  termed 
the  decidua  rejiexa. 

Tlie  space  between 
the  decidua  vera  and  ru- 
flexa  is  filled  by  opaque, 
viscid  mucus. 
The  Placenta, — The  villi  which  cover  the  chorion  become  imbedded 
in  the  soft  tissues  of  the  decidua,  and  derive,  by  absorption,  nutritive 
materials  from  the  circulatory  system  of  the  mother.  After  the  for- 
mation of  the  permanent  chorion,  by  the  extension  of  the  allantois  to 
the  inner  surface  of  tlie  Q^g.,  the  allantoic  vessels  convey  the  absorbed 
materials  directly  to  the  embryo.  At  first,  absorption  takes  place  from 
the  entire  circumference  of  the  chorion,  but  with  the  enlargement  of 
the  ovum  there  ensues  a  thinning  of  the  reflexa,  with  obliteration  of 
its  vessels.  At  the  same  time  the  villi  cease  to  grow  over  that  portion 
of  the  chorion  in  contact  with  the  reflexa,  and  the  whole  process  of 
exchange  between  foitus  and  mother  becomes  concentrated  at  the  de- 
cidua serotina.  At  this  point  the  chorion,  in  place  of  becoming  bare, 
is  covered  with  an  infinite  multitude  of  villi,  which  enlarge,  lengthen, 
and,  by  sending  out  lateral  offshoots,  assume  an  arborescent  appear- 
ance. The  villi  are  arranged  in  tufts,  sixteen  to  twenty  in  number, 
which  together  form  a  soft,  spongy  mass,  and  constitute  the  fetal 
portion  of  the  placenta. 

The  uterine  mucous  membrane,  in  which  the  villi  lie  imbedded, 
contributes  likewise  its  share  to  the  muke-up  of  the  completed  pla- 

*  Leopold,  in  his  account  of  the  uterine  mucous  membrane,  adopts  Reichert's 
view  of  the  formation  of  the  reflexa.  viz.,  that,  owin^  to  the  less  rapid  increase  in 
the  growth  of  the  serotina,  the  ovum  becomes  buried  in  the  thickening  of  the  vera. 
— {Vide  Studien  ilberdie  Uterusschleimhaut.  etc.,  Arch.  f.  Gynaek.,  Bd.  xi,  p.  455.) 
In  opposition  to  the  accepted  view  that  the  decidua  is  the  tumefied  mucous  mem- 
brane, Ercolani  (On  the  Utricular  Glands  of  the  Uterus,  translated  by  Marcy) 
insists  that  both  the  vera  and  reflexa  are  organs  of  new  formation,  the  products  of 
exudations,  the  neo-formative  process  consisting  in  the  production  of  new  vessels 
with  single  endothelial  walls,  from  tbe  surface  of  which  the  decidual  cells  are 
elaborated. 


DEVELOPMENT   OP   THE   OVUM.  55 

centa.  The  structure  of  this  so-called  maternal  portion  of  the  organ 
has  been  the  subject  of  much  difference  of  opinion.  Indeed,  an  in- 
telligible idea  of  its  anatomy  can  hardly  be  conveyed  without  a  pre- 
liminary consideration  of  certain  points  connected  with  its  develop- 
ment. 

Thus,  the  villi  are  often  erroneously  described  as  penetrating  direct- 
ly into  the  glandular  structures  of  the  adjacent  uterine  mucous  mem- 
brane. Professor  Turner  has,  however,  conclusively  shown  that,  in  all 
the  less  complicated  placental  forms  throughout  the  animal  kingdom, 
the  depressions  or  cryjits  into  which  the  villi  dip  occupy  the  soft, 
pulpy,  interglandular  tissues.  Engelmann  further  draws  attention  to 
the  large  size  of  the  terminal  sprouts  of  the  villi  in  the  human  placenta, 
which  would  render  their  entrance  into  the  glandular  tubules,  unless 
by  a  mere  exceptional  chance,  a  mechanical  impossibility.  Moreover, 
Friedliinder  *  has  demonstrated,  as  will  be  again  noted  hereafter,  the 
persistence  of  the  enlarged  flattened  glands  in  the  serotina  even  after 
the  separation  of  the  i)lacenta  at  childbirth.  It  may  be  deemed,  there- 
fore, as  fairly  settled  that  the  maternal  portion  of  the  placenta  is  de- 
rived from  the  tissues  occupying  the  spaces  between  the  glands,  and 
not  from  the  glands  themselves. 

In  the  mare,  the  relations  of  the  villi  to  the  uterine  mucosa  are  of 
the  simplest  character.  With  a  little  force  it  is  possible  to  draw  the 
villi  from  the  crypts,  which,  on  vertical  section,  are  seen  to  be  cup- 
like depressions  between  the  glands.  The  crypts  are  surrounded  by 
a  dense  capillary  plexus,  and  are  lined  by  eiDithelial  cells.  The  epi- 
thelial cells  are  partly  columnar,  like  those  covering  the  mucous 
membrane  of  the  uterus  in  the  unimpregnated  state,  while  others  are 
so  swollen  out  that  their  length  but  little  exceeds  their  breadth, 
while  others  are  of  irregular  shape.  Transitional  forms  prove  the 
derivation  of  the  irregularly  shaped  cells  from  ordinary  columnar 
epithelium,  f 

In  the  arrangement  just  described,  it  will  be  seen  that  the  villi 
containing  the  vessels  communicating  with  the  foetus  dip  into  crypts 
in  the  uterine  mucous  membrane.  The  crypt-walls  are  highly  vascu- 
lar, and  are  lined  with  epithelium.  There  is,  therefore,  no  direct  com- 
munication between  the  fetal  and  maternal  blood-vessels.  The  crypts, 
however,  elaborate  a  secretion,  termed  by  Haller  uterine  milk,  which 
contains  fatty,  saline,  and  albuminous  matters  dissolved  in  water.  The 
uterine  milk  is,   therefore,  well  qualified  to  serve  as  a  nutrient  mate- 

*  Friedlander,  Untersuchungen  iiber  den  Uterus,  1870— Ueber  die  Innenflache 
des  Uterus  post  partura,  Arch.  f.  Gynaek.,  Bd.  ix,  p.  22,  1876.  Friedlander's  ob- 
servations have  been  confirmed  by  Kundrat  and  Engelmann,  Langlians,  and 
Leopold. 

t  Professor  Turner,  The  Structure  of  the  Placenta,  Jour,  of  Anat.  and  Physiol., 
vol.  X,  p.  136. 


56 


PHYSIOLOGY  OF  THE   OVUM. 


rial,  and  is  without  doubt  absorbed  by  the  villi  for  the  benefit  of  the 

foetus.* 

In  the  cat,  the  villi  of  the  chorion  have  the  form  of  broad,  sinuous 
leaflets,  which,  about  the  completion  of  one  half  the  period  of  gesta- 
tion, are  so  interlocked  with  the  crypts  that  the  two  surfaces  can  not 
be  diseno-aged  from  one  another.  Vertical  sections  show  that  the  walls 
of  the  crypts  closely  follow  the  sinuosities  of  the  villi  in  such  wise  as 
to  form  an  intimate  investment  for  them.  Injections  of  the  maternal 
capillaries  show  them  to  be  dilated  to  two  or  three  times  the  size  of 
the  capillaries  in  the  fetal  villi. f 

In  the  human  placenta  the  relations  of  the  villi  to  the  uterine  mu- 
cous membrane  differ  somewhat  at  different  stages  of  development. 


I 


Fig.  48.— Diagram  showing  the  branching  of  the  vilH  and  the  connection  of  the  larger  trunks 
with  the  placenta.  «,  chorion  ;  b,  primary  trunk,  with  radiate  branches  (o;  t/,  tlie  tertiary 
branches,  which  either  directly,  or  after  previous  division  (rf'i,  penetrate  the  placenta  ma- 
terna  (/).    The  free  terminal  tufts  (e)  are  indicated  only  at  a  few  points.     (Langbaus.) 


Thus,  at  first,  the  empty  cylindrical  villi  simply  sink  into  the  soft, 
pulpy,  interglandular  spaces.  Next,  as  the  villi  sprout  and  become  vas- 
cular and  arborescent,  projections  formed  from  the  proliferation  of 
the  superficial  portion  of  the  serotina  grow  around  the  oft'shoots  and 
branching  processes.  At  this  time  we  distinguish  in  the  placenta  a 
fetal  portion,  the  placenta  foetalis,  composed  of  the  villous  tufts  of  the 

*  The  uterine  milk  can  not  be  obtained  from  the  placenta  of  the  mare  unmixed 
with  the  secretions  from  the  uterine  glands.  The  analyses  of  Professors  Prevost. 
Schlossberger,  and  Gamgee  were  made  upon  a  fluid  derived  from  polycotyledonous 
placenta?.— ( Vide  Structure  of  the  Placenta,  p.  176.)  Hoffmann  (Sicherer  Xachweis 
der  Uterinmilch  beim  Menschen,  Ztschr.  f.  Geburtsk.  und  Gynaek,  Bd.  vili,  p.  258) 
claims  to  have  demonstrated  the  presence  of  uterine  milk  in  the  human  placenta 
likewise.  This  he  obtained  by  the  insertion  of  capillary  tubes  into  the  substance  of 
the  placenta  from  its  maternal  surface.  The  fluid  consisted  of  serum,  of  some  of 
the  formed  elements  of  the  blood,  and  of  a  multitude  of  spherical  bodies  which  he 
regarded  as  analogous  to  m.ilk  globules.  Werth,  however  (Ueber  die  sogenannte 
Uterinmilch  des  Menschen.  Arch,  f,  Gynaek..  Bd.  xxii.  p.  233),  has  shown  that  this  so- 
called  uterine  milk  is  a  post-mortem  production,  not  present  directly  after  delivery  ; 
that  the  serous  portion  is  derived  from  the  villi,  and  the  formed  elements  from  the 
exochorial  cells. 

f  Turner,  op.  cit.,  pp.  155,  156. 


DEVELOPMENT   OP   THE   OVUM.  57 

ovum,  and  a  uterine  portion,  the  placenta  uterina,  derived  from  the 
tissues  of  the  serotina. 

In  the  third  and  fourth  months  the  union  of  the  fetal  and  maternal 
tissues  is  very  intimate.  But  subsequently  the  growth  of  the  uterine 
tissue  does  not  keep  pace  with  that  of  the  villi,  so  that  the  mature 
placenta  is  almost  altogether  a  fetal  organ.  A  layer  of  uterine  mu- 
cosa, not  exceeding  ^^  of  an  inch  in  thickness,  covers  the  surface  of 
the  placenta  after  delivery.  Between  the  cotyledons,  however,  thin 
partitions  from  the  serotina  extend  downward  for  a  considerable  dis- 
tance, thougli  never,  except  near  the  borders,  as  far  as  the  chorion. 

Sections  through  the  hardened  placenta  show  that  the  main  villous 
trunks  divide  at  a  short  distance  from  the  chorion.  The  secondary 
branches  assume  a  radiate  direction,  from  which  proceed  tertiary 
branches,  which  terminate  in  club-shaped  extremities  and  bury  them- 
selves in  the  serotina.  From  these  tertiary  branches  fine  lateral  ones, 
having  a  dendritic  arrangement,  are  given  off,  and  fill  the  spaces  be- 
tween tlie  tertiary  trunks. 

Many  of  these  lateral  tufts  are  attached  directly  to  the  serotina, 
and  fill  up  in  part  the  interval  between  the  larger  radiate  branches ; 
others,  again,  float  freely  in  the  blood-currents  derived  from  the  ma- 
ternal vessels.* 

The  precise  origin  and  nature  of  the  vascular  spaces  between  the 
villi  have  been  a  prolific  subject  of  discussion.  In  the  early  months, 
we  saw,  the  scrotinal  projections  extended  deep  down  between  the 
villi,  and  contained  largely  dilated  capillaries ;  and  yet  afterward 
every  trace  of  these  vessels  is  found  to  have  disappeared  throughout 
the  entire  placenta,  except  in  the  thin  layer  of  the  placenta  uterina, 
where  the  endothelium,  or  inner  lining,  may  still  be  detected.  The 
most  probable  supposition  is,  that  the  vessels  have  become  eroded 
and  finally  destroyed  by  the  growth  of  the  villi,  leaving  the  blood  to 
flow  unimpeded  tlirough  the  intervillous  spaces.  A  delicate  layer  of 
epithelium  may,  indeed,  be  found  upon  the  villous  trunks  and  tufts ; 
but  these,  it  is  sufficiently  established,  belong  to  the  villi,  and  are  de- 
rived from  the  exochorion.f  Whether  these  cells  essentially  modify 
the  interchange  between  the  fetal  and  maternal  circulations,  can  only 
be  a  matter  of  conjecture.  The  fact  that  certain  medicinal  substances, 
such  as  iodide  of  potassium  and  salicylic  acid,  when  administered  dur- 

*  Langhans,  Zur  Kenntniss  der  menschlichen  Placenta,  Arch.  f.  Gynaek.,  Bd.  i, 
1870,  p.  317;  vide  also  Kolliker,  Entwickelungsgeschichte ;  Leopold,  Der  Bau 
der  Placenta,  Arch.  f.  Gynaek.,  Bd.  xi,  1877,  p.  443. 

t  Kolliker,  Entwickelungsgeschichte,  2te  Auflage,  p.  333;  Leopold,  Der  Bau 
der  Placenta,  Arch.  f.  Gynaek.,  Bd.  xi,  p.  467.  It  is,  however,  proper  to  state  here 
that  Ercolani  maintains  that  the  dilated  endothelial  walls  of  the  maternal  vessels 
are  simply  bent  inward  by  the  proliferating  villi,  and  that  the  epithelium  observed 
upon  the  villi  are  decidual,  and  are  not  derived  from  the  exochorion.  Vide  Marcy,. 
N.  Y.  Med.  Journal,  July  28  and  Aug.  4,  1883. 


58 


PHYSIOLOGY  OF  THE   OVUM. 


ing  the  latter  days  of  pregnancy,  may  be  found  in  the  blood  and 
secretions  of  the  fcetus,  whereas  others,  as  woorari  and  perhaps  mer- 
cury, have  not  been  so  found,  renders  some  action  on  the  part  of  the 
cells,  aside  from  simple  osmosis,  at  least  probable.* 

The  Structure  of  the  Fully-developed  Placenta.— The  placenta, 
after  its  removal  from  the  body,  is  found  to  be  a  soft,  si)ongy  mass,  of  a 


Ch  f<7ti 


V         ^.R.LAtErt. 


Fio.  49— Diagram  of  uterus  and  placenta  in  the  fifth  month.     CVi,  clioriou  ;  Am,  amnion  ;  V, 
villi ;  L,  lacunae;  6',  serotina  ;  AH,  areolar  ;   I",  small  arteries.    (Leoiwld.) 


somewhat  oval  shape.  It  measures  upward  of  seven  and  a  lialf  inches 
in  its  longest  diameter,  is  from  two  thirds  to  an  inch  in  thickness  at 
the  point  of  insertion  of  the  funis,  and  weighs  about  sixteen  ounces. 
Its  internal  surface  is  smooth,  and  is  covered  by  the  amnion,  through 
which  the  vessels  communicating  with  those  of  tlie  funis  can  be  seen 

*  Vide  Fehling,  Zur  Lehre  der  Stoffwechsel,  Arch.  f.  Gebtirtsk..  Bd.  ix.  p.  313; 
Beneke,  Ztschr.  f.  Geb.  und  Frauenkrankheiten.  Bd.  i.  i».  477:  Gusserow,  Arch.  f. 
Geburtsk.,  Bd.  iii,  p.  241 ;  Schauesstei.v  und  Spaeth.  Jahrb.  dor  Kinderhoilk.,  2ter 
'iJahrg.,  p.  18 ;  R.  Heinz,  Arch.  f.  Gynaek..  Bd.  .xxxiii,  p.  413 ;  Unter.'^uchungen  iiber  den 
Bail  und  die  Entwickehiiig  der  menschlichen  Placenta.  Heinz  states  that  on  the  bor- 
ders of  the  placenta  a  portion  of  decidual  ti.'^sue  is  pushed  under  the  placenta  (2  to  3 
cm.),  and  at  this  point  septa  may  be  found  penetrating  the  placenta  to  the  subchorial 
layer  of  the  decidua.  Detached  portions  of  decidual  tissue  sometimes  are  found  in 
placental  tissue.  At  term  the  villi  have  no  epithelial  covering.  In  the  early  months 
cell  coverings  may  be  seen  here  and'  there,  but  are  derived  from  the  villi.  The 
remains  of  glandular  structures  described  by  Friedlander,  after  separation  of 
decidua,  are  not  found  in  the  serotina  at  the  end  of  pregnancy.  The  separation 
must  therefore  take  place  from  the  borders  in  the  puerperal  period,  when  the  point 
at  which  placental  separation  has  taken  place  is  of  small  .size.  Heinz  observed 
specific  instances  where  the  villi  penetrated  directly  into  the  lumina  of  the  decidual 
glands,  but  leaves  open  the  question  whether  they  likewise  , penetrate  into  the 
interglandular  tissue.     Heinz's  view  of  placenta  formation  is  as   follows:   Villi 


DEVELOPMENT  OP  THE  OVUM.  5q 

in  their  distribution  over  tlie  surfuce  of  the  organ  previous  to  plung- 
ing into  the  tissues  beneath.  The  uterine  surface  has  a  peculiar,  gran- 
ular feel,  and  is  divided  into  a  number  of  lobes,  corresponding  to  the 
fetal  tufts  or  cotyledons  already  described.  It  is  covered  with  a  soft, 
thin  membrane,  which  sends  septa  or  partitions  in  between  the  cotyle- 
dons. This  membrane  is  simply  the  product  of  the  surface  layer  of 
the  serotina. 

Curled  arteries  from  the  uterus  penetrate  the  cotyledons,  and  con- 
vey the  maternal  blood  into  the  spaces  or  lacuna?  between  the  fetal 
tufts.  Through  these  spaces  the  blood  flows  in  a  sluggish  current, 
and  is  conveyed  back  to  the  uterus  by  the  coronary  vein  upon  the 
margin  of  the  i)lacenta,  and  by  means  of  sinuses  situated  in  the  septa 
between  the  cotyledons,  and  continuous  with  the  venous  sinuses  of  the 
uterine  walls.*  The  fetal  tufts  which  thus  bathe  in  the  mother's 
blood  receive,  through  the  umbilical  arteries,  the  blood  which  comes 
from  the  fcetus,  darkened  with  carbonic  acid.  In  the  ultimate  rami- 
tications  of  the  villi,  the  arteries  communicate  by  an  arch  or  loop  with 
a  corresponding  branch  of  the  umbilical  vein,  which  returns  to  the 
cliild  red,  arterialized  blood. f 

liut  the  placenta  is  not  simply  a  respiratory  organ.  The  rapid  de- 
velopment of  tlie  ovum,  from  a  simple  cell  of  microscopic  size  to  the 
proportions  of  the  infant  at  birth,  argues  as  surely  that  the  relations 
of  the  blood-currents  in  tiie  placenta  enable  the  fcetus  to  derive  from 
the  mother  all  the  proximate  principles  required  for  the  building 
up  of  tissue,  the  diiferentiation  of  organs,  and  the  performance  of 
function. 

Then,  too,  the  fa?tus  has  been  shown  to  have  a  temperature  of  its 
own,  somewhat  higher  than  tluit  of  the  mother.];  This  production  of 
heat  is  necessarily  attended  with  destruction  of  tissue.     Of  this  there 

penetrate  tlie  deoidim  and  chiefly  enter  gland  stnictnres,  break  through  the  gland 
wallj:.  and  destroy  maternal  tissue,  with  the  exception  of  small  remnants,  which  per- 
sist as  islets.  Villi  grow  into  dilated  vessels,  and  bathe  freely  in  them.  The  opened 
vessels  pour  the  l)lood  into  the  intervillous  spaces.  In  the  mature  placenta  there 
remains  of  decidua  only  the  serotina,  one  half  to  one  millimetre  thick.  The  septa 
and  the  islets  are  evidence  that  serotinal  tissue  once  existed  near  the  chorion,  but 
was  destroyed  by  growth  of  villi. 

*  For  alTirmative  evidence  f)f  the  existence  of  placental  lacunae,  vide  Professor 
TcRXER,  Structure  of  the  Human  Placenta,  Jour,  of  Anat.  and  Physiol.,  vol.  vii,  p. 
120.  So,  too.  Professor  Daltox's  ingenious  inflation  of  the  intervillous  spaces  with 
air,  Treatise  on  Human  Physiology,  1867,  p.  615.  For  objections,  the  elaborate 
paper  of  Braxtox  Hicks,  in  the  London  Obstet.  Trans.,  vol.  xiv,  deserves  careful 
perusal. 

+  Vide  experiments  of  Zweifel,  Die  Respiration  des  Fojtus,  Arch.  f.  Gynaek., 
Bd.  ix,  p.  293.     See  also  Berard,  t.  iii,  p.  422,  experiments  of  Legallois. 

,  X  WuRSTER.  Ueber  die  Eigenwarme  der  Neugebornen,  Berl.  klin.  Woch.,  Nr.  87, 
1869 ;  Alexeef,  Ueber  die  Temperatur  d6s  Kindes  im  Uterus,  Arch.  f.  Gynaek.,  Bd. 
X,  p.  141. 


60 


PHYSIOLOGY   OF   THE   OVUM. 


is  evidence  in  the  presence  of  urea  in  the  bladder  and  the  amniotic 
fluid.  There  can  be  little  question,  however,  but  that  the  placenta 
furnishes  the  chief  channel  through  which  the  devitalized  products  are 
discharged. 

The  Formation,  of  the  Umbilical  Cord. 

To  understand  the  structure  of  the  cord,  it  is  well  to  bear  in  mind 
the  various  particulars  connected  with  its  development.  At  the  time 
when  the  allantois  first  appears  as  a  sac-like  projection  from  the  intes- 
tine, the  embryo  is  hardly  more  than  an  appendage  to  the  umbilical 
vesicle.  The  larger  size  of  the  latter  directs  the  allantois  over  the 
posterior  extremity  of  the  foetus.     By  its  growth  and  extension,  the 


Fig.  50.— a,  umbilical  arteries  forming  spirals  (1  ]')  around  the  vein  ;  constrictions  indicating 
the  presence  of  folds  (3,  3');  circular  folds  (.5,  .5');  lateral  openings  showing  the  arterial  walls. 
B,  vein  opened  upon  the  side,  showing  a  constriction  (2)  correspondiiiK  to  an  interior  valve 
(3"i;  semi-lunar  valves  (3,  3',  3")  C,  section  of  vein  and  arteries  showing  valve  of  vein  (1», 
a  semi-lunar  arterial  valve  (2),  and  a  circular  arterial  valve  (3).    (Tarnier  et  Chantreuil.) 

allantois  reaches  the  chorion,  and  forms  a  sort  of  pedicle,  by  means  of 
which  a  vascular  communication  is  established  between  the  embryo 
and  the  periphery  of  the  ovum.  This  pedicle  is  the  first  indication  of 
the  umbilical  cord.  Its  vessels  become  reduced  to  two  arteries,  the 
umbilical  arteries,  and  a  single  vein,  the  umbilical  vein.  Meantime, 
the  umbilical  vesicle  diminishes  in  size,  and  finally  shrinks  to  a  mere 
thread.  The  amnion  fills  with  fluid,  exuded  probably  from  the  body 
of  the  foetus,  and  continues  to  expand,  so  that  often  by  the  end  of  the 


DEVELOPMENT  OF  THE  OVUM. 


61 


second  month  it  comes  in  contact  with  the  chorion.*  In  this  way  it 
forms  a  reflection  over  the  pedicle  of  the  aUantois,  which  it  invests 
like  the  finger  of  a  glove.  Finally,  the  structure  of  the  cord  is  com- 
pleted by  the  formation  of  an  elastic  substance,  termed  the  gelatine  of 
Wharton^  which  consists  of  connective-tissue  elements  inclosing  large 
spaces  containing  amorphous  matter.  The  gelatine  of  Wharton  func- 
tionally serves  to  protect  the  vessels  of  the  cord  from  compression. 
It  is  formed  by  hypergenesis  from  the  outer  layers  of  the  amnion  and 
the  allantois,  both  of  which  are  derived  from  the  intermediate  layer, 
described  in  the  development  of  the  foetus  {vide  p.  50).  The  interme- 
diate layer  furnishes,  likewise,  the  connective  tissue  of  the  body. 

The  fully-developed  cord  consists,  therefore,  of  a  sheath  from  the 
amnion,  the  gelatine  of  Wharton,  the  umbilical  vein  and  arteries,  and 
traces  of  the  umbilical  vesicle,f  and  the  pedicle  of  the  allantois.J  It 
averages  twenty  inches  in  length,  though  it  has  been  observed  as  long 
as  seventy  inches,  and  as  short  as  two  and  a  half  inches.*  A  long  cord 
predisposes  to  the  formation  of  coils  about  the  neck,  body,  and  limbs 
of  the  foetus.  It  is  usually  of  about  the  size  of  the  little  finger,  but  is 
very  variable,  its  circumference  depending  chiefly  upon  the  quantity 
of  the  gelatine  of  Wharton.  The  arteries  are  so  twisted  as  to  form 
spiral  turns  around  the  vein,  and,  owing  to  the  superior  length  of  the 
right  artery,  in  most  cases  in  the  direction  from  right  to  left.  As  an 
anatomical  peculiarity,  may  be  mentioned  the  fact  that  the  walls  of 
the  arteries  are  only  slightly  thicker  than  those  of  the  vein.  The 
arteries  as  well  as  the  vein  contain  semi-lunar  valves. 

The  Amniotic  Fluid. — The  origin  of  the  amniotic  fluid  in  the  ear- 
lier months  of  gestation  is  not  known,  the  most  probable  suggestion 
being  that  it  is  simply  exuded  from  the  tissues  of  the  foetus.  After 
the  formation  of  the  placenta,  a  capillary  network,  connected  with  the 
vessels  of  the  umbilical  cord,  is  developed  just  beneath  the  amnion  in 
that  portion  of  the  chorion  which  covers  the  placenta.  From  these 
vessels  a  transudation  of  serum  takes  place  into  the  cavity  of  the 
amnion. II  After  the  first  half  of  pregnancy  has  been  reached,  the 
capillary  network  disappears.  The  continued  increase  of  fluid  in  the 
amnion  in  the  later  months  of  gestation  is  possibly  due  to  the  accu- 
mulation of  urine,  which  the  fcetus  passes  intermittently  during  intra- 
uterine existence.^     The  composition  of  the  amniotic  fluid  corresponds 

*  Vide  Hunter's  Gravid  Uterus,  plate  xxxiii,  Fig.  2 ;  Ecker,  Icon.  Physiolog., 
plate  xxxiii,  Fig.  7. 

f  ScHULTZE,  Das  Nabelblaschen,  ein  constantes  Gebilde,  etc.,  Leipsic,  1861. 
X  Ahlfeld,  Die  Allantois  des  Menschen,  Arch.  f.  Gynaek.,  vol.  x,  p.  81. 

*  Chantreuil,  Des  Dispositiens  du  Corden,  Paris,  1875. 

J  JuNGBLUTH,  Beitrag  zur  Lehre  vom  Fruchtwasser,  Inaug.  Dissert.,  Bonn,  1869. 

^  Gusserow,  Zur  Lehre  vom  Stoffwechsel  des  Foetus,  Arch.  f.  Gynaek..  vol.  iii, 
pp.  268,  269.  Prochownick,  Beitrage  zur  Lehre  vom  Fruchtwasser  und  seiner  Ent- 
stehung,  Arch.  f.  Gynaek.,  vol.  xi.  p.  304.     Krukenberg,  Kritische  und  experi- 


62 


PHYSIOLOGY  OF  THE  OVUM. 


to  its  double  origin.  In  addition  to  water  it  contains  albumen,  urea, 
and  the  saline  substances  which  are  found  in  serum  and  urine.  Its 
quantity  varies  usually  between  one  and  two  pints,  of  which  nearly  one 
half  is  contributed  during  the  last  three  lunar  months.* 

Ahlfeld  concludes  from  the  great  quantities  of  lanugo  found  in  the 
meconium  that  the  child  of  necessity  during  intra-uterine  life  swallows 
a  very  considerable  quantity  of  amniotic  fluid.  As  no  fluid  is  found 
at  birth  in  the  intestinal  canal,  the  fluid  was  of  necessity  absorbed.  As 
the  amniotic  fluid  contains  albumen,  in  certain  cases  the  precipitate 
amounting  to  from  twenty-five  to  fifty  per  cent,  he  believes  this  al- 
buminosus  contributes  something  to  the  nourishment  of  the  child. 
Richard  Schroeder,  on  the  contrary,  regards  the  quantity  of  albumen 
in  the  amniotic  fluid  as  too  small  to  contribute  appreciably  to  fetal 
nutrition. 


CHAPTER   III. 

DEVELOPMENT  OF  THE  F(ETUS. 

Development  of  the  foetus  in  the  successive  months  of  pregnancy. — Fetal  circula- 
tion.— Fcetus  at  term. — Fetal  cranium. — Attitude,  presentation  and  position 
of  foetus. 

Development  of  the  Fcetus  ix  the  Successive  Months  of 

Pregnancy. 

It  is  customary  to  reckon  the  duration  of  pregnancy  at  two  hun- 
dred and  eighty  days,  and  to  divide  that  space  into  ten  months  of 
twenty-eight  days  each.  As  it  is  often  a  matter  of  importance  that  an 
accoucheur  should  be  able  to  judge  the  age  of  a  prematurely  expelled 
embryo  or  fcetus,  the  following  particulars  concerning  the  olianges  in 
each  month  are  furnished  as  a  guide  to  the  formation  of  an  ojnnion. 
In  the  writer's  experience  all  rules  regarding  the  age  of  the  ovum  pos- 
sess, however,  nothing  more  than  an  approximative  value,  owing  to  the 
very  great  normal  variations  in  the  rapidity  of  development  in  different 
individual  cases. 

First  Montli. — At  the  end  of  the  second  week,  the  embryo  is  repre- 
sented by  the  embryonic  spot,  which  has  assumed  a  biscuit-shape.  The 
dorsal  plates  are  developed.  The  entire  ovum  measures  one  fourth  of 
an  inch,  and  the  embryo  one  twefth  of  an  inch.  A  week  later  the 
embryo  has  doubled  in  length,  and  presents  as  special  features  a  curv- 

mentelle  Untersuchungen  ueber  die  Herkunft  des  Fruehtwassers,  Arch  f.  Gvnaek., 
vol.  xxii,  p.  1. 

*  OussEROw,  /.  c,  p.  269.  F.  Ahlfeld,  In  Wie  Weit  das  Fruchtwasser  ein  Nahr- 
ungsmittel  fur  die  Frucht  ist,  Zt.  f.  Geb.  und  Gynaek.,  vol.  xiv,  p.  405. 


DEVELOPMENT  OF  THE  FCETUS. 


63 


mg  of  the  back,  an  enlargement  of  the  cephalic  extremity,  with  rudi- 
ments of  the  three  higher  organs  of  special  sense,  and  the  appearance 
of  the  visceral  arches.  The  amnion  is  fully  developed.  The  embryo  is 
nourished  by  the  umbilical  vesicle.  The  allantois  carries  the  vessels 
from  the  embryo  to  the  periphery  of  the  ovum,  but  the  vessels  do  not 
penetrate  the  villi.  An  ovum  described  by  Waldeyer,  exactly  four 
weeks  old,  was  of  about  the  size  of  a  pigeon-egg,  and  three  fourths  of 
an  inch  long  by  two  thirds  of  an  inch  broad.  It  weighed  upward  of 
two  scruples.     The  embryo  measured  nearly  one  third  of  an  inch  in 


Fig.  51.— Human  germs  or  embryos  from  the  second  to  the  fifteenth  week  (natural  size),  seen 
from  the  left  side,  the  arched  back  turned  toward  the  right.  (Principally  after  Ecker.)  II, 
human  embryo  of  fourteen  days  ;  III.  of  three  weeks  ;  IV,  of  four  weeks  ;  V,  of  five  weeks  ; 
VI,  of  six  weeks  ;  VII,  of  seven  weeks  ;  VIII.  of  eight  weeks  ;  XII,  of  twelve  weeks  ;  XV,  of 
fifteen  weeks. 

length,  or  four  fifths  of  an  inch  in  length  following  the  dorsal  curva- 
ture from  the  top  of  the  cephalic  extremity  to  the  end  of  the  coccyx. 
The  head  of  the  embryo  presented  the  primitive  cerebral  vesicles. 
The  eyes  were  in  the  sides  of  the  head,  and  the  ears  posterior  to  the 
eyes.  Beneath,  the  visceral  arches  were  well  marked.  Four  bud- 
like processes  indicated  the  beginnings  of  the  anterior  and  posterior 
extremities.  The  intestine,  with  anal  and  oral  openings,  was  formed. 
The  cord  was  short  and  thick,  with  a  single  vein  and  two  arteries. 
The  amnion  was  only  moderately  distended,  and  space  still  existed 


64 


PHYSIOLOGY  OF  THE   OVUM. 


between  the  amnion  and  cliorion     The  umbilical  vesicle  was  tolerably 

large. 

Second  Month.— An  embryo  described  by  Waldeyer  from  the  sixth 
to  the  seventh  week  measured  about  one  inch  in  length,  following  the 
dorsal  curve.  Another  in  the  eighth  week  described  by  Ecker  meas- 
ured two  thirds  of  an  inch  in  a  direct  line  from  the  head  to  the  caudal 
curve.*  The  ovum  itself  was  of  about  the  size  of  a  hen's  egg.  The 
amnion  at  the  end  of  the  second  month  is  distended  with  fluid  and  in 
contact  with  the  chorion. f  The  villi  become  abundant  near  the  im- 
plantation of  the  umbilical  cord.  The  umbilical  vesicle  is  greatly  re- 
duced in  size,  and  hangs  from  the  embryo  by  a  slender  pedicle.  The 
umbilical  cord  is  increased  in  length,  but  its  vessels  do  not  yet  assume 
a  spiral  direction.  The  umbilical  ring  is  small,  though  still  containing 
loops  of  intestine.  Ossification  begins  in  the  lower  jaw  and  clavicle. 
The  three  divisions  of  the  extremities  are  clearly  indicated. 

Third  Month. — Toward  the  end  of  the  third  month  the  ovum  meas- 
ures nearly  four  inches  in  length.  The  embryo  is  between  three  and 
three  and  a  half  inches  long,  and  weighs  about  an  ounce.  The  chorion 
has  lost  in  great  measure  its  villosities.  The  placenta  is  formed,  though 
of  small  size.  The  cord  lengthens,  and  forms  spiral  turns.  The  neck 
now  separates  the  head  from  the  trunk  The  development  of  the  ribs 
distinguishes  the  thorax  from  the  abdomen.  The  mouth  is  closed  by 
the  lips,  and  the  nasal  se2)arated  from  tiie  oral  cavity  by  the  palate. 
Points  of  ossification  appear  in  most  of  the  bones.  Thin,  membrane- 
like nails  appear  upon  the  fingers  and  toes.  The  scrotum  and  labia 
majora  begin  to  form  from  cutaneous  folds.  The  penis  and  clitoris  do 
not  difl:er  from  one  another  in  length. 

Fourth  Month. — Toward  the  end  of  the  fourth  month  there  is  an 
increase  of  size  and  thickness  in  the  placenta.  The  cord  is  increased 
to  two  or  three  times  the  length  of  the  fatus,  and  has  become  thicker 
from  the  formation  of  the  gelatine  of  Wharton.  The  fwtus  measures 
four  to  six  inches  in  length.  The  weight  is  estimated  all  the  way  be- 
tween two  and  four  ounces.  The  head  of  the  ftetus  is  one  fourth  the 
length  of  the  entire  body.  The  bones  of  the  skull  are  partly  ossified. 
The  sutures  and  fontanelles  are  widely  separated.  The  mouth,  eyes, 
ears,  and  nose  assume  their  proper  shape.  The  sex  is  distinguishable, 
the  skin  firmer,  and  hair  begins  to  form  upon  the  scalp.  The  foetus 
makes  slight  movements  with  its  limbs. 

Fifth  Month. — The  foetus  measures  from  seven  to  ten  inches  in 
length,  and  weighs  nearly  ten  ounces.  The  head  is  still  relatively 
large.  The  face,  however,  is  wrinkled,  and  wears  a  senile  aspect.  Fine 
hair  (lanugo)  appears  over  the  whole  surface  of  the  body.  The  fetal 
movements  are  now  distinctly  felt  by  the  mother. 

*  Spiegelberg,  Lehibuch  der  Geburtshiilfe,  p.  84. 
f  Loc.  ciL,  p.  84. 


DEVELOPMENT  OF  THE  FCETUS. 


65 


Sixth  Month. — Near  the  end  of  the  sixth  month  the  foetus  is  eleven 
to  thirteen  inches  long  and  weighs  about  twenty-three  ounces.  The 
deposition  of  fat  in  the  subcutaneous  cellular  tissue  begins.  The  eye- 
lids separate.  A  foetus  born  at  this  time  breathes  feebly,  but  in  the 
course  of  a  few  hours  dies. 

Seventh  Month. — The  fa?tus  measures  fourteen  to  fifteen  inches,  and 
weighs  in  the  neighborhood  of  thirty-nine  ounces.  The  skin  is  still 
wrinkled,  of  a  red  color,  and  covered  with  vernix  caseosa.  Children 
born  between  the  twenty-fourth  and  the  twenty-eighth  week  move 
their  limbs  and  cry  feebly  at  birth,  but  in  spite  of  every  care  they  die 
in  the  course  of  a  few  hours  or  days. 

Note. — Ahlfeld  has  recently  suggested  the  inquiry  as  to  whether  the  assump- 
tion that  children  born  before  the  completion  of  tlie  twenty-eighth  week  neces- 
sarily perish  is  not  too  arbitrary.  Many  practitioners  have  observed  instances  of 
the  survival  of  a  premature  child  which,  both  from  the  data  obtained  from  the 
parents  and  from  all  the  indications  presented  by  the  child,  they  at  the  time  of 
birth  had  placed  within  tlie  limit  regarded  as  hopeless.  Ahlfeld  has  culled  a  num- 
ber of  such  cases  from  the  published  literature  of  the  subject.  Granting  the  many 
sources  of  error  which  would  lead  us  to  accept  such  cases  with  caution,  it  none  the 
less  seems  incumbent  upon  us  to  regard  Ahlfeld's  advice,  and  look  upon  every  child 
which  respires  at  birth  as  one  whose  life  may  possibly  be  preserved  by  suitable 
care.  It  may  be  that  the  skepticism  of  medical  men  is  in  part  the  cause  of  the 
unfavorable  results.* 

Eighth  Month. — The  foetus  measures  sixteen  to  seventeen  inches, 
and  weighs  upon  the  average  about  fifty-two  ounces.  The  pupillary 
membrane  disappears  ;  the  hair  of  the  head  increases  in  thickness ;  the 
lanugo  begins  to  disappear  from  the  face  ;  the  nails  are  harder,  but  do 
not  yet  reach  the  tips  of  the  fingers.  Usually,  in  boys,  a  testicle  may 
be  felt  in  the  scrotum ;  the  navel  is  situated  nearly  in  the  center  of  the 
child's  body.  With  care,  the  life  of  a  child  born  within  this  period 
may  be  preserved. 

Ninth  Month.— The  length  is  between  sixteen  and  a  half  and  seven- 
teen and  a  half  inches ;  the  weight  is  about  sixty-four  ounces ;  the  body 
becomes  rounded  and  the  face  more  comely,  losing  its  wrinkled,  anti- 
quated aspect;  the  bones  of  the  head  bend  easily,  and  the  lanugo 
begins  to  disappear  from  the  body.  Children  at  this  period  are  less 
energetic  than  at  full  term,  sleep  a  great  part  of  the  time,  and  are  prone 
to  die  with  lack  of  careful  attention. 

Tenth  Month.— In  the  first  two  weeks  the  fa?tus  measures  eighteen 
to  nineteen  inches,  and  weighs  about  seventy-seven  ounces,  f 

*  Ahlfeld,  Ueber  unzeitig  und  sehr  fruhzeitig  geborene  Friichte  die  am  Leben 
blieben.  Arch.  f.  Gynaek.,  Bd.  viii,  p.  194. 

t  The  weights  and  measures  are  taken  from  Hecker's  averages,  based  on  486 
observations.     ( Vide  Monatssehr.  f .  Geburtsk.,  Bd.  xxvii,  1866.) 

Observations  of  Fesser  showed  similar  results.  (Lehrbuch  der  Geburtshiilfe,  von 
Otto  Spiegelberg,  1877,  p.  86.) 

Ahlfeld  obtained  considerably  larger  averages  from  250  observations  in  which 
5 


g^  PHYSIOLOGY   OP   THE  OVUM. 

For  convenience  of  reckoning  from  memory  it  is  sufficiently  accu- 
rate to  assume  the  length  of  the  child  in  the  third  and  fourth  month 
at  respectively  three  and  four  inches.  In  the  fifth,  sixth,  seventh,  and 
eighth  months  close  approximations  to  the  average  length  may  be 
obtained  by  doubling  the  number  of  months.  In  the  ninth  and  tenth 
months  the  length  may  be  placed  respectively  at  seventeen  and  eight- 
een inches. 

The  Fetal  Circulation. — The  umbilical  arteries  at  first  take  their 
origin  from  the  inferior  vertebral  arteries,  and  afterward  from  the 
hypogastric  or  internal  iliac  arteries. 

The  umbilical  vein  enters  the  abdomen  at  the  navel,  and  thence 
passes  to  the  lower  surface  of  the  liver;  it  gives  off  a  number  of 
branches  to  the  left  lobe,  the  lobus  quadratus,  and  the  lobus  Spigelii. 
At  the  transverse  fissure  it  divides  into  two  branches,  the  larger  of 
which  empties  directly  into  the  portal  vein,  and  supplies  the  right  lobe 
with  umbilical  blood  ;  the  other  passes  to  the  inferior  vena  cava,  and 
is  termed  the  ductus  venosus.  Thus  the  greater  portion  of  the  regen- 
erated blood,  brought  by  the  umbilical  vein  from  the  placenta,  first 
passes  through  the  liver  before  entering  the  general  circulation  of  the 
foetus,  while  the  lesser  amount  empties  at  once  into  the  inferior  vena 
cava.  As,  however,  with  the  advance  of  gestation,  the  relative  dispro- 
portion between  the  hepatic  trunks  and  the  ductus  venosus  is  in- 
creased, toward  the  end  nearly  all  the  blood  from  the  placenta  has  to 
make  the  circuit  of  the  liver. 

Thus  the  inferior  vena  cava  carries  to  the  right  auricle,  in  part, 
blood  from  the  lower  extremities  charged  with  effete  matters,  and,  in 
part,  placental  blood,  either  received  direct  from  the  umbilical  vein 
through  the  ductus  venosus,  or  after  having  previously  traversed  the 
liver. 

In  the  foetus  the  currents  of  blood  through  the  heart  are  especially 
adapted  to  the  unexpanded  condition  of  the  pulmonary  organs.  Previ- 
ous to  the  first  respiratory  act  at  birth,  the  lung  is  small,  and,  were 
the  entire  contents  of  the  right  side  of  the  heart,  as  in  the  adult,  at 
once  discharged  into  the  pulmonary  vessels,  intense  engorgement  with 
rupture  of  the  capillaries  would  ensue.  This  danger  is,  however, 
averted  by  the  anatomical  peculiarities  already  stated.  Thus,  in  the 
early  months  the  blood  from  the  inferior  cava,  in  place  of  emptying 
from  the  right  auricle  into  the  right  ventricle,  passes  directly  across 
the  right  auricle,  guided  by  the  Eustachian  valve,  through  the  foramen 
ovale  to  the  left  auricle,  and  thence  to  the  left  ventricle.  As  the  heart 
contracts  it  enters  the  aorta,  and  is  distributed  by  the  large  vessels 
which  spring  from  the  latter  to  the  head  and  upper  extremities.  The 
blood  returned  from  the  upper  portion  of  the  body  by  the  superior 

the  date  of  conception  could  be  determined.     (Bestimmungen  der  Grosse  und  des 
Alters  der  Frucht  vor  der  Geburt,  Arch.  f.  Gynaek.,  ii,  1871,  p.  361.) 


DEVELOPMENT  OF  THE  FCBTUS. 


67 


vena  cava  enters  the  right  auricle,  where  it  passes  in  front  of  the 
Eustachian  valve  into  the  right  ventricle.  A  commingling  of  the 
currents  from  the  superior  and  inferior  venae  cavae  in  the  right  auricle 


Pulmonary  Art. 

Foramen  Ovale 

Ji'ustachian  Valve. 
Right  Aurtc.  -  Vent.  Opening. 


Hepatic  Vein. 

Branf/i(s  of  the 
Umbilical  Vetn, 
to  the  Liver. 


Bladder 


Pulmonary  Art. 
Left  Auricle. 
....Left  Awic.  ■  Vent. 
Opening. 


g  Ductus  VenotHS, 


Internal  Iliac  Arteries. 
Fig.  52.— Diagram  of  the  fetal  circulation.     (Fjiii.... 


68 


PHYSIOLOGY  OF  THE  OVUM. 


is  almost  completely  prevented  in  the  earlier  months  by  the  Eustachian 
valve.  With  the  advance  of  gestation,  however,  a  gradual  disappear- 
ance of  the  Eustachian  valve  takes  place,  so  that  a  part  of  the  blood 
from  the  inferior  cava  enters  with  that  of  the  superior  cava  into  the 
right  ventricle.  The  contraction  of  the  right  ventricle  forces  the  blood 
into  the  pulmonary  artery,  which  distributes  an  insignificant  quantity 
to  the  lungs,  while  the  main  current  passes  through  the  ductus  arteri- 
osus into  the  aorta,  ly  which  it  is  distributed  to  the  lower  portion  of 
the  body. 

Thus  it  will  be  noted  that  at  all  times  provision  is  made  for  sup- 
plying the  head  and  upper  parts  of  the  body  with  regenerated  placen- 
tal blood.  On  the  other  hand,  the  lower  extremities  are  for  a  time 
almost  entirely  supplied  with  blood  which  has  already  fed  the  tissues 
and  received  the  waste  of  the  upper  portion  of  the  body.  As  preg- 
nancy, however,  advances  with  the  disappearance  of  the  Eustachian 
valve,  a  small  measure  of  placental  blood  is  likewise  distributed  to  the 
lower  portion  of  the  body.  This  is  in  unison  with  the  well-known 
fact  that  the  relative  development  of  the  lower  extremities  increases  as 
the  end  of  gestation  is  approached. 

With  the  cessation  of  the  placental  circulation  at  birth,  the  um- 
bilical vessels  close,  with  the  exception  of  the  umbilical  arteries,  which 
remain  pervious  at  their  lower  portion  and  constitute  the  vesical  arte- 
ries. After  the  establishment  of  respiration,  the  blood  from  the  right 
side  of  the  heart  makes  the  circuit  of  the  lungs  and  returns  to  the  left 
side  by  the  pulmonary  veins.  The  ductus  arteriosus  then  contracts 
and  disappears.  As  the  left  auricle  fills  with  blood,  the  pressure  closes 
the  valve  of  the  foramen  ovale.  Occasionally,  however,  the  foramen 
ovale  remains  open  after  birth,  and  allows  a  portion  of  the  venous 
blood  to  pass  from  the  right  to  the  left  auricle.  We  have  then  one 
form  of  the  condition  known  as  cyanosis  neonatorvm^  an  affection 
characterized  by  intermittent  attacks  of  dyspnoea,  blueness  of  the  sur- 
face of  the  body,  and  depression  of  the  temperature. 

The  Foetus  at  Term.— In  the  child  at  birth  the  body  is  well  rounded, 
and  the  skin  has  lost  its  deep-red  coloring ;  the  fine  down  (lanugo) 
has,  for  the  most  part,  disappeared ;  the  nails  project  beyond  the  fin- 
ger-tips ;  in  the  male  the  scrotum  contains  both  testicles,  and  in  the 
female  the  labia  majora  are  in  "contact.  In  the  fifth  month  the  sur- 
face of  the  fetal  body  is  covered  by  the  vernix  caseom,  a  whitish  sub- 
stance composed  of  a  commingling  of  surface  epithelium,  down,  and 
the  products  of  the  sebaceous  glands.  This  coating  probably  protects 
the  skin  during  intra-uterine  life  from  the  penetration  of  the  amniotic 
fluid.  The  amount  of  this  substance  upon  the  body  is  very  variable 
at  birth,  when  it  is  chiefly  found  upon  the  back  and  flexor  surfaces  of 
the  extremities. 

Children  at  term  cry  lustily  soon  after  birth,  move  their  limbs 


DEVELOPMENT  OF  THE  FCETUS. 


69 


freely,  and  nurse  when  put  to  the  breast.  In  the  first  few  hours  they 
pass  urine  and  the  so-called  meconium^  a  mixture  of  intestinal  mucus 
with  epithelium,  epidermis  cells,  lanugo,  and  bile,  which  gives  to  it  a 
black  or  brownish-green  color.* 

The  average  length  at  birth  is  from  twenty  to  twenty-one  inches. 
The  average  weight  seems  to  be,  in  some  degree,  dependent  upon  race 
peculiarities.  Scunzoni  f  found,  in  nearly  0,000  births,  an  average  for 
both  sexes  of  nearly  seven  pounds.  Ingerslev,J  in  Copenhagen,  from 
statistics  based  upon  3,-450  births,  arrived  at  nearly  the  same  results. 
Hecker,*  in  Munich,  out  of  something  over  1,000  births,  obtained  six 
and  four  fifths  pounds  as  the  average  ;  wliile  Fesser,  ||  in  Breslau,  found 
it  only  six  and  a  half  pounds.  Bailly  ^  likewise  reports  the  average 
weight  as  something  less  than  seven  pounds.  The  weights  of  200 
infants  born  in  the  Bellevue  Hospital  gave  to  the  writer  an  average  of 
seven  and  two  thirds  pounds  for  the  two  sexes.  The  boys  averaged 
seven  and  nine  tenths  pounds,  and  the  girls  seven  and  one  third 
pounds.  Three  fourths  of  the  mothers  were  of  Irish  birth,  one  fifth 
were  born  in  America,  while  the  remaining  fraction  was  divided  be- 
tween English,  Scotch,  and  Germans.  The  largest  child  weighed 
eleven  pounds.  Ingerslev's  largest  child  weighed  ten  and  three  eighths 
pounds  ;  Hecker  found  two  weighing  between  ten  and  eleven  pounds ; 
La  Chapelle,  out  of  7,000  cases,  found  thirteen  infants  weighing  ten 
pounds,  but  none  exceeded  that  limit.  Credible  histories  I)  of  children 
weighing  from  twelve  to  sixteen  pounds  are  extant;  such  children 
have  often  been  still-born.  Waller,  however,  J  reports  a  case  of  a  living 
infant  delivered  by  him  with  forceps,  which  weighed  fifteen  pounds 
fifteen  ounces.  I  have  extracted  with  forceps  a  living  child  which 
weighed  over  fifteen  pounds.  Dr.  C.  W.  Gleavis,  of  Wytheville,  Va., 
writes  me  that  a  lady  in  that  place  gave  birth  to  a  living  male  child 
which  weighed  eighteen  pounds.  The  size  of  the  child  is  influenced 
in  especial  by — 1.  The  sex.  Boys  average  a  greater  weight  than  girls. 
2.  The  number  of  pregnancies.  The  children  of  primiparae  average 
less  than  those  of  multiparfe.  The  increase  in  weight  of  children  in 
each  successive  pregnancy  is  progressive,  though  this  law  is  liable  to  in- 
terruption where  pregnancies  follow  one  another  too  rapidly,  or  in  cases 

*  ZwEiFEL,  Untersuchungen  iiber  das  Meconium,  Arch.  f.  Gynaek.,  Bd.  vii,  1875, 
p.  474. 

f  ScANZONi,  Lehrbuch  der  Geburtshiilfe,  p.  96. 

X  Ingerslev's  On  the  Weight  of  New-born  Children,  Obstet.  Jour.,  iii,  1876, 
p.  705. 

*  Klinik  der  Geburtskunde,  ii,  1864. 

II  Spiegelberg,  Lehrbuch  der  Geburtshiilfe,  p.  86. 
^  Bailly,  Nouveau  Dictionnaire,  t.  xv,  art.  Foetus,  p.  5. 

0  Naegele's  Lehrbuch  der  Geburtshiilfe,  bearbeitet  von  Grenser,  8te  Auflage, 
p.  624. 

X  Waller,  London  Obstet.  Trans.,  vol.  i,  p.  309. 


70 


PHYSIOLOGY  OF   THE   OVCJM- 


in  which  there  is  a  change  of  sex.  In  the  latter  instance  the  variation 
is  to  the  disadvantage  of  the  female  born  in  succession  to  a  male.* 
3.  The  age  of  the  mother.  Duncan  found  the  greatest  weight  in 
children  born  of  mothers  between  the  twenty-fifth  and  twenty-ninth 
years ;  f  Wernich,  between  the  thirtieth  and  thirty-fourth  years.  I  4. 
The  constitution  and  health  of  the  parents.  By  some,  too,  the  size 
of  the  father  is  sup^josed  to  exercise  an  influence  upon  that  of  the 
child. 

The  Fetal  Cranium.— Except  in  children  of  exaggerated  size,  the 
head  is  the  most  voluminous  and  unyielding  part  which  has  to  traverse 
the  parturient  canal.*  The  diameters  of  the  head  and  the  physical  char- 
acters of  its  bones  are  chiefly  of  importance  in  connection  with  the  mech- 
anism of  labor.  Their  consideration  may,  therefore,  be  conveniently 
postponed  to  the  study  of  that  subject.  A  knowledge,  however,  of  the 
general  structure  of  the  skull  is  essential  to  the  diagnosis  of  pregnancy. 

The  face  is  very  small  in  proportion  to  the  cranium.  The  latter 
consists  of  the  two  frontal  bones,  the  two  parietal  bones,  the  occipital 
bone,  the  temporal  bones,  and  the  alfe  of  the  sphenoid  bone.  At  birth 
these  various  bones  are  not,  as  in  the  adult,  directly  articulated  together, 
but  are  united  by  means  of  fibrous  bands,  termed  sutures,  in  which  ossi- 
fication subsequently  takes  place.  It  is  important  to  become  familiar 
with  the  following  sutures  :  1.  The  fronfal  xnture,  between  the  frontal 
bones.  2.  The  sagittal  suture,  between  the  two  parietal  bones.  3.  Tlie 
coronal  siiture,  between  the  frontal  and  parietal  bones.  4.  The  lambda 
suture,  between  the  occipital  and  two  parietal  bones. 

When  three  or  more  bones  meet  together,  the  rounded  angles  of  the 
bones  offer  at  the  point  of  concurrence  a  deficiency  of  osseous  substance, 
which  is  closed  by  fibrous  membrano  similar  to  that  which  forms  the 
sutures.  These  membranous  interspaces  are  termdd  foyitanelles.  Two 
of  these,  the  large  anterior  and  the  small  posterior  fontanelle,  are  of 
immediate  obstetrical  interest,  as  they,  with  the  sutures,  furnish  the 
guiding  points  which  enable  the  examining  finger  to  determine,  in  ad- 
vanced pregnancy,  the  position  of  the  child's  head. 

The  large  fontanelle,  or  bregmatic  space  (bregma,  the  sinciput), 
occupies  the  gap  between  the  parietal  and  frontal  bones.  It  possesses 
a  lozenge-shape.  Its  anterior  angle  is  continuous  with  the  frontal 
suture,  its  posterior  angle  with  the  sagittal  suture,  and  its  lateral 
angles  with  the  two  halves  which  compose  the  coronal  suture.  Its  an- 
terior angle  is  much  longer  than  the  posterior  angle. 

The  small  fontanelle  is  situated  at  the  junction  of  the  occipital  with 

*  Wernich,  Ueber  die  Zunahme  der  weiblichen  Zeugungsfahigkeit,  Beitr.  zur 
Geburtsh.,  Bd.  1.  p.  3. 

t  Duncan,  Fecundity,  Fertility,  and  Sterility,  p.  53. 
X  hoc.  cit.,  p.  10. 

*  In  bulky  children,  the  shoulders  sometimes  ofEer  the  greatest  diflBculties  in 
delivery. 


DEVELOPMENT   OF   THE   FCETUS. 


71 


Fio 


53.— Fetal  skull,  seen  from  tlie  side.     T  F,  tuber  parietale  :  L.  lambda  suture  ;  OM,oc- 
cipito-iuental  diameter  ;  C,  coroual  suture.    (J.  Veit.) 


Fig.  54.— Fetal  skull  seen  from  above. 


TT,  bitemporal  diameter  ;  FP,  bi-parietal  diameter. 
(J.  Veit.) 


Y2  PHYSIOLOGY   OF  THE  OVUM. 

the  parietal  bones.  It  is  of  a  triangular  shape,  and,  as  its  name  indi- 
cates, of  small  size.  As  a  rule,  it  no  longer  exists  at  birth,  owing  to 
the  complete  ossification  of  the  angles  which  form  it. 

The  anterior  fontanelle  may  be  recognized  by  the  finger,  during 
labor,  by  its  large  size,  its  lozenge-shape,  and  by  its  four  converging 
sutures  which  cross  one  another  at  right  angles.  The  posterior  fon- 
tanelle, on  the  contrary,  is  small  and  triangular ;  the  sagittal  suture 
forms,  with  the  lambda  suture,  an  obtuse  angle  on  either  side,  and  ter- 
minates at  the  occipital  bone.  During  the  descent  of  the  child's  head 
into  the  pelvis,  the  occipital  bone  is  frequently  depressed  beneath  the 
parietal  bones,  which  thus  form  a  relief,  along  which  the  finger  readily 
passes  to  the  site  of  the  small  fontanelle,  even  when  the  latter  no  longer 
exists  as  an  open  gap  or  space. 

The  Attitude,  Pkesentatiox,  and  Position  of  the  Foetus. 

The  attitude  of  the  foetus  i/i  ntero  is  as  follows :  The  spinal  col- 
umn is  bent  forward,  the  chin  is  inclined  toward  the  chest,  the  arms 
are  bent  at  the  elbow  and  the  forearms  are  crossed  upon  the  breast, 
the  thighs  are  flexed  upon  the  abdomen,  and  the  feet  extended  so 
as  to  come  in  contact  with  the  legs,  which,  like  the  forearms,  are 
often  crossed.  By  this  arrangement  the  fci'tus  assumes  the  smallest 
bulk,  and  presents  an  ovoid  form,  of  which  the  head  furnishes  the 
smaller  end. 

By  presentation  we  understand  that  portion  of  the  foetus  which  oc- 
cupies the  lower  segment  of  the  uterus.  By  the  determination  of  the 
presentation,  we  are  enabled  to  decide  upon  the  relation  of  the  axis  of 
the  child  to  the  long  diameter  of  the  uterus.  When  these  two  coin- 
cide, either  of  the  two  extremities  of  the  child,  viz.,  the  head  or  the 
breech,  becomes  the  presenting  part.  When  the  long  diameter  of  the 
child  corresponds  to  the  oblique  or  transverse  diameter  of  the  uterus, 
the  shoulder  becomes  the  presenting  part. 

Though  head-presentations  form,  during  labor,  by  far  the  large 
majority  of  all  cases  (ninety-six  per  cent.),  changes  of  position  are  very 
common  during  pregnancy.  The  frequency  of  these  changes  is  in 
inverse  ratio  to  the  advance  of  pregnancy,  occurring  with  diminished 
frequency  in  the  later  months.  In  multiparae  they  take  place  oftener 
than  in  primiparae.  In  multiparse  they  occur  not  rarely  shortly  before 
birth,  while  it  is  exceptional  in  primiparae  for  them  to  take  place  in 
the  last  three  weeks  of  pregnancy.  Great  ingenuity  has  been  exercised 
to  account  for  the  preponderating  frequency,  at  the  time  of  labor,  of 
head-presentations.  Hippocrates  taught  that,  during  the  early  months 
of  pregnancy,  the  fojtus  occupied  a  sitting  posture,  with  the  head 
uppermost.  In  the  seventh  month,  however,  it  made  a  complete 
turn  or  somersault  preparatory  to   its   exit  from   the  womb,  an  act 


DEVELOPMENT   OP   TUE   FOETUS. 


73 


accomplished  by  the  vohmtary  efforts  of  the  child.  Aristotle  referred 
the  head-presentations  to  the  laws  of  gravity,  a  theory  which  has 
always  had  many  adherents  and  is  still  actively  defended  at  the  pres- 
ent day.* 

Dubois  f  made  a  serious  breach  in  this  doctrine  by  showing  that  if 
he  allowed  a  dead  fa?tus,  of  any  period  between  the  fourth  and  ninth 
months,  to  sink  in  a  vessel  filled  with 
water,  it  was  not  the  head,  but  the 
back  or  right  shoulder  which  first 
reached  the  bottom.  Dubois  there- 
upon denied  the  influence  of  gravity, 
and  referred  the  head-presentations  to 
instinctive  or  voluntary  movements  on 
the  part  of  the  foetus,  designed  to 
bring  it  into  a  position  best  adapted 
for  intrauterine  domicile,  or  for  par- 
turition. He  likewise  argued  against 
the  gravitation  theory,  that  in  pre- 
mature births,  and  in  children  who 
die  in  utero,  pelvic  and  transverse  pre- 
sentations are  very  common — a  fact 
that  would  be  inexplicable  were  grav- 
ity the  sole  or  chief  force  in  opera- 
tion. Simpson  J  agreed  with  Dubois 
in  ascribing  the  cephalic  presentations 
to  fetal  movements,  but,  in  place  of 
the  instinctive  or  voluntary  movements 
of  Dubois,  substituted,  in  an  argument 
of  extraordinary  ingenuity,  a  theory 
of  reflex  action.  Thus,  the  frequency 
of  mal-positions  in  the  first  six  months 
of  pregnancy  was    explained   by  the 

spheroidal  shape  of  the  uterine  cavity,  which  allows  of  unrestrained 
fetal  movements.  In  the  later  months,  however,  as  the  uterus  assumed 
a  more  ovoid  shape,  it  was  only  when  the  child  was  situated  in  the 
uterus  with  the  head  lowest  that  a  physical  adaptation  between  icetus 
and  uterus  existed.  In  case  from  any  cause,  therefore,  a  deviation 
from  this,  the  normal  position,  took  place,  the  pressure  upon  the  cuta- 
neous surface  of  the  child,  by  the  uterine  wall,  would  give  rise  to  excito- 

*  Vide  historical  part  of  Cohnstein's  paper  entitled  Die  Aetiologie  der  normalen 
Kinderlage,  Monatssch.  f.  Geburtsk.,  Bd.  xxxi,  p.  142. 

t  Dubois,  Memoire  sur  la  cause  des  presentations  de  la  tete,  Mem.  de  I'Acad. 
Roy.  de  Med.,  tome  ii,  1833,  p.  265. 

t  Simpson,  Attitude  and  Positions  of  the  Foetus  in  Utero,  Obstetric  Works, 
edited  by  Priestley  and  Storer,  vol.  ii,  p.  81. 


Fig.  55.— Attitude  of  foetus  in  ntero. 
(Tarnier  et  Chantreuil.) 


^^  PHYSIOLOGY  OF  THE   OVUM. 

motory  movements  of  an  adaptive  kind,  calculated  to  restore  the  dis- 
turbed presentation.  Duncan*  and  Yeit  succeeded  in  partially  re- 
habilitating the  gravitation  theory  by  sliowing  that,  notwithstanding 
Dubois's  experiinents,  the  center  of  gravity  lies  much  nearer  the 
cephalic  than  the  pelvic  extremity  of  the  child.  They  found  that  a 
fresh  fa?tus  immersed  in  a  saline  fluid  possessing  nearly  the  same  spe- 
cific gravity  as  the  foetus,  in  place  of  sinking  upon  its  back  or  side  to 
the  bottom  of  the  vessel,  assumed  an  oblique  direction  in  the  fluid 
with  the  right  shoulder  looking  downward,  f  They  therefore  con- 
cluded that  the  foetus,  lying  upon  the  inclined  plane  furnished  by 
the  uterine  walls,  would  naturally  assume  a  similar  position  were  no 
other  forces  operative  to  interfere.  Crede,  Kristeller,|  and  Braxton 
Hicks*  maintain  that  the  contractions  of  the  pregnant  uterus  adapt 
the  position  of  the  foetus  to  the  form  of  the  uterus.  Veit  believes 
that  the  stability  of  the  foetus  is  insured  by  the  descent  in  advanced 
pregnancy  of  the  presenting  part  below  the  level  of  the  pelvic  brim. 

Now,  each  one  of  these  conflicting  ideas  undoubtedly  represents  a 
portion  of,  but  not  all,  the  truth.  It  is  certain  that  the  influences 
cited  do  exist,  and  it  only  remains  for  us  clinically  to  assign  to  each  its 
relative  value.  In  the  early  months  of  pregnancy,  the  spheroidal 
shape  of  the  uterine  cavity,  the  small  size  of  the  fcrtus  in  comparison 
with  that  of  the  uterus,  and  the  large  proportion  of  amniotic  fluid,  all 
allow  the  foetus  the  greatest  measure  of  mobility.  At  this  time  the 
position  of  the  child  must  be  influenced  by  the  active  movements 
which  are  felt  by  the  mother  subjectively  often  as  early  as  the  four- 
teenth week.  As  usually,  during  the  first  half  of  pregnancy  even, 
the  shoulder  and  head  are  turned  downward,  it  is  fair  to  ascribe  tliis 
position  to  the  laws  of  gravity.  The  frequency  of  malpresentations  in 
premature  labors  is  explained  in  part  by  the  tardy  dilatation  of  the 
cervix  and  the  mobility  of  the  foetus,  which  render  easy  the  displace- 
ment of  the  head  from  its  first  position,  under  the  influence  of  pressure 
exerted  upon  the  axis  of  the  child's  body.  Malpresentations  are  more 
frequent  in  the  case  of  a  dead  foetus  than  in  the  living,  but  Duncan 
has  shown  that  in  the  dead  foetus,  owing  to  post-mortem  changes,  the 
center  of  gravity  often  shifts  toward  the  pelvic  extremity.  With  the 
advance  of  pregnancy,  as  the  longitudinal  exceeds  the  lateral  growth 
of  the  uterus,  the  child  adapts  itself  to  the  long  axis  of  the  uterus, 
and  the  furthei  pregnancy  advances  the  more  complete  the  adaptation 
becomes.  When  from  any  cause  or  condition  the  correspondence  be- 
tween the  fetal  and  uterine  axis  is  disturbed,  compression  of  a  portion 
of   the   cutaneous   surface  of  the  foetus  results.     Reflex  movements, 

*  Duncan,  Researches  in  Obstetrics,  p.  14.  Yeit,  Scanzoni's  Beitrage,  Bd.  iv,  p.  279. 
f  On  account  of  the  liver  upon  the  right  side. 

X  Vide  Schroeder's  Handbuch  der  Geburtshiilfe,  4te  Auflage,  p.  47. 

*  Hicks,  Contractions  of  Pregnant  Uterus,  Obstet.  Trans.,  p.  224. 


I 


DEVELOPxMENT  OF   THE   FCETUS.  ^5 

especially  in  the  lower  extremities,  are  excited,  which  restore  the  fcetus 
to  that  position  in  which  it  enjoys  the  most  complete  freedom  from 
discomfort.  Often,  too,  the  uterine  walls  resent  the  pressure  of  the 
foetus,  and,  by  their  contractions,  serve  to  maintain  the  body  of  the 
child  in  the  uterine  axis. 

In  cases  of  hydramnios  the  conditions  more  nearly  resemble  those 
which  exist  in  early  pregnancy  ;  hence  malpresentations  occur  with 
greater  frequency,  favored  by  the  mobility  of  the  fcetus  in  the  surplus- 
age of  amniotic  fluid.  Per  contra,  when,  as  is  the  case  toward  the 
end  of  normal  pregnancies,  the  fcetus  nearly  fills  the  intra-uterine 
space,  the  movements  are  very  restricted,  and  displacements  rare. 

In  primiparous  women,  the  pyriform  shape  of  the  uterus  in  the 
later  months  is  most  marked,  and  as  a  consequence  the  head  of  the 
child  is  usually  held  by  the  uterine  walls  in  the  pelvic  cavity.  In 
multipara?,  on  the  contrary,  owing  to  the  relaxation  of  the  uterine 
parietes,  it)  is  usual  for  the  child,  in  obedience  to  the  laws  of  gravity, 
to  lie  somewhat  obliquely  in  the  uterus,  with  its  head  resting  upon  one 
of  the  iliac  fossa?.  As  soon  as  labor  begins,  however,  the  uterine  con- 
tractions carry  the  head  to  the  axis  of  the  superior  strait  of  the  pelvis. 

The  changes  in  the  fetal  presentation  are  not,  however,  confined 
to  simple  conversions  from  an  oblique  to  an  upright  direction,  or  to 
shiftings  of  position  iy  obedience  to  laws  of  gravity.  But  even  in  ad- 
vanced pregnancy  a  breech-presentation  may  become  a  head-presenta- 
tion, and  vice  versa*  P.  Miiller  reported  a  case  in  which  the  foetus 
made  six  such  revolutions  within  five  days.f  Now,  it  can  not  be  sup- 
posed that  the  difficulties  which  the  foetus  must  encounter  from  the 
resistance  of  the  short  transverse  diameter  of  the  uterus  could  be  over- 
come by  such  comparatively  feeble  forces  as  gravity,  or  reflex  adapt- 
ive movements,  or  partial  uterine  contraction.  In  Miiller's  case  the 
changes,  if  the  mother's  story  be  correct,  must  have  taken  ^place  not 
gradually  but  suddenly,  and  by  the  vigorous  movements  of  the  child's 
limbs.  Meeh  |  calls  attention  to  the  fact  that  the  movements  of  the 
child  are  produced  chiefly  by  the  extension  of  the  lower  extremities, 
and  argues  that  these  movements  aid  to  a  greater  extent  in  changing 
the  presentation  of  the  child  when  the  breech  occupies  the  lower  seg- 
ment of  the  uterus,  because  of  the  solid  resistance  offered  by  the  bony 
pelvic  ring,  while  in  head-presentations  the  pressure  of  the  extremities 
against  the  elastic  fundus  is  in  the  rule  unavailing  to  effect  any  con- 
siderable changes  of  position. 

*  ScHROEDER,  Schwang.,  Geb.  u.  Wochenbett,  Bonn,  1867,  p.  31 ;  Schultze, 
Unters.  uber  den  Wechsel  der  Lage,  etc.,  Leipsic,  1868 :  Fassbender,  Berl.  Beitrage 
zur  Geb.  und  Crvnaek.,  Bd.  i,  p.  41. 

t  ScAxzoNi's  Handbueh  der  Geb.,  4te  Auflage,  p.  123. 

X  Meeh.  Warum  komrat  das  Kind  am  haufigsten  in  der  Kopfendlage  zur  Welt  f 
Arch.  f.  Gynaek.,  vol.  xx,  p.  185. 


Yg  PHYSIOLOGY  OF  THE  OVUM. 

By  position  is  designated  the  relation  of  a  determinate  point  in  the 
body  of  the  foetus  to  the  uterine  walls.  In  head  or  breech  presenta- 
tions, the  back  of  the  child  is  most  commonly  turned  to  the  left,  which, 
hence,  is  termed  the  first  position.  The  back  turned  to  the  right  is 
known  as  the  second  position,  and  occurs  with  much  less  frequency. 

In  the  first  position  the  back  is  usually  directed  somewhat  ante- 
riorly, while  in  the  second  position  it  is  turned  rather  to  the  rear. 
T.n  shoulder-presentations  the  back  is  usually  directed  to  the  front. 
Changes  of  position  are  frequent  in  pregnancy,  and  take  place,  Avhen 
other  influences  do  not  prevent,  in  obedience  to  laws  of  gravity.  When 
the  woman  stands  erect,  the  axis  of  the  uterus  is  continuous  with  the 
axis  of  the  superior  strait  of  the  pelvis,  and  forms  with  the  horizon  an 
angle  of  thirty-five  degrees.  The  uterus  does  not  occupy  exactly  the 
median  line,  but  lies  more  to  the  right.  It  is  also  twisted  slightly  upon 
its  axis,  so  that  the  left  lateral  portion  is  directed  somewhat  to  the 
front.  In  the  upright  position,  therefore,  the  anterior  wall  of  the 
uterus  not  only  forms  an  inclined  plane,  but  one,  too,  with  a  down- 
ward drop  toward  the  left  side.  Now,  if  these  relations  be  borne  in 
mind,  it  w\l  be  readily  seen  that  the  child,  resting  upon  the  inclined 
plane  furnished  by  the  anterior  wall,  with  its  right  shoulder  directed 
downward,  must,  if  left  to  itself,  turn  with  its  back  to  the  left  side  of 
the  uterus.  In  the  recumbent  posture,  the  axis  of  the  uterus  forms 
with  the  horizon  an  angle  of  thirty  degrees,  and  the  downward  slope  is 
to  the  right  side.  The  child,  now  resting  upon  the  inclined  plane 
furnished  I^j;;  the  posterior  wall,  with  its  right  shoulder  directed  down- 
ward, would  naturally  turn  with  its  back  to  the  right  side  of  the  uterus. 
These  considerations  are  not  purely  theoretical,  as,  when  the  conditions 
have  been  such  as  to  allow  the  foetus  latitude  of  movement,  the  changes 
indicated  in  the  fetal  position  followed  changes  in  the  attitude  of  the 
mother.* 

The  position  of  the  child  has  heretofore  been  determined  by  that 
of  the  child's  head  when,  after  the  advent  of  labor,  the  head  has  been 
brought  within  reach  of  the  examining  fingers.  Sutugin,  however, 
maintains  that,  during  pregancy,  if  the  patient  be  examined  in  the  re- 
cumbent position,  the  back  is  nearly  always  turned  to  the  rear  whether 
it  be  situated  to  the  right  or  the  left  of  the  spinal  column.  Changes  of 
position  by  posterior  rotation  he  believes  are  not  uncommon. f 

*  HiJxixG,  Scanzoni's  Beitrage,  Bd.  vii,  p.  99. 

t  Sutugin,  Beitrage  zum  Mechanismus  der  Geburt  bri  SchOdellagen.     Klinische 

Vortrage,  No.  310. 


PHYSIOLOGY   OF   PREGiN'AE'OY. 


CHAPTER   IV. 

CHANGES  EFFECTED  IN  THE  MATERNAL   ORGANISM  BY 
PREGNANCY. 

Changes  in  the  sexual  apparatus  and  neighboring  organs. — Changes  in  the  uterus. 
— Explanation  of  apparent  shortening  of  cervix. — Changes  in  the  vagina, 
vulva,  abdomen,  navel,  breasts,  nipple. — Functional  disturbances  of  bladder. — 
Constipation. — CEdema. — Changes  effected  in  the  entire  organism. 

Changes  occuruixg  ix  the  Sexual  Apparatus  axd 
Neighboring   Organs. 

The  pregnant  state  is  signalized  by  the  nutritive  energy  imparted 
by  the  fecundated  ovum  to  the  generative  organs  and  to  the  viscera  in 
their  vicinity. 

The  uterus,  from,  the  inception  of  pregnancy,  increases  in  vascu- 
larity. Its  mucous  membrane  becomes  soft  and  thickened.  The  mus- 
cular fibers  are  increased  seven  to  eleven  times  in  length,  and  three 
to  five  times  in  width.  During  the  first  five  months  new  muscular 
fibers  are  developed,  especially  upon  the  inner  layer  of  the  uterus. 
The  delicate  connective-tissue  processes  between  the  muscular  fibers 
become  more  abundant,  and  toward  the  termination  of  pregnancy 
display  distinct  fibrillar.  The  vessels  increase  in  number,  length,  and 
circumference.  The  arteries,  as  we  have  noticed,  assume  a  spiral 
course,  and  in  places  communicate  directly  with  the  veins.  The  veins 
are  dilated,  and  form,  especially  in  the  placental  region,  wide-meshed 
networks.  The  walls  of  the  veins  are  intimately  united  with  the 
muscitlar  walls  of  the  uterus,  and  form,  when  divided,  open-mouthed 
canals.  The  lymphatics,  starting  from  the  spongy  tissues  of  the  lin- 
ing mucous  membrane,  traverse  the  muscular  structures,  and  are 
gathered  up  by  abundant  plexuses,  which  are  distributed  especially 
over  the  fundus  and  sides  of  the  womb.  The  nerves  increase  in  length 
and  thickness,  and  grow  inward  toward  the  uterine  cavity.  Upon  the 
inner  surface  of  the  uterus  ganglia  may  be  observed.*  The  ganglion 
cervicale,  Avhich  measures  in  the  non-pregnant  condition  three  fourths 
of  an  inch  in  length  and  half  an  inch  in  width,  is  now  an  inch  and  a 
half  in  breadth,  and  possesses  a  length  of  two  inches. 

*  Spiegelberg,  Handbuch  der  Geburtshiilfe,  p.  50. 


^^  PHYSIOLOGY  OF   PKEGNANCY. 

These  textural  changes  are  accompanied  by  an  enormous  increase  in 
the  vohime  of  the  uterus.  The  weight  of  the  latter  in  the  virgin  state 
is  about  an  ounce,  while  toward  the  end  of  pregnancy  it  weighs  in  the 
neighborhood  of  two  pounds.  The  increase  in  the  bulk  of  the  uterus 
is  progressive.  The  following  table,  by  Arthur  Farre,*  furnishes  ap- 
proximate measurements  for  the  different  months  of  pregnancy  : 

Length.  Width. 

End  of  3d  month 4^-5  inches,  4  inclies. 

4th      "     


5th 
6th 
7th 
8th 
9th 


5i-6       ' 

5 

6  -7      " 

5J 

8  -9      " 

6i 

10      ' 

7i 

11      ' 

8 

12      ' 

9 

According  to  Levret,  the  surface  of  the  virgin  uterus  msasures  six- 
teen square  inches,  while  that  of  the  pregnant  uterus  at  term  measures 
three  hundred  and  thirty-nine  square  inches. f  The  uterine  cavity  is 
stated  by  Krause  to  be  enlarged  five  hundred  and  nineteen  times. | 

The  enlargement  of  the  uterus  is  not  due,  in  the  beginning  of 
pregnancy  at  least,  to  the  pressure  of  the  expanding  ovum,  for  the 
same  changes  occur  during  the  first  four  months  in  cases  of  extra- 
uterine pregnancy.  In  the  latter  months,  however,  a  mechanical 
stretching  is  probable,  as  the  walls  become  thinned  and  conform  to 
the  size  of  the  ovum.  At  term,  the  walls  are  not  of  uniform  thickness, 
but  vary  between  one  sixth  and  one  fourth  of  an  inch. 

In  pregnancy  the  muscular  fibers  of  the  uterus,  as  has  been  shown 
by  Ruge,  Hofmeier,  and  others,  are  arranged  in  groups,  which  possess 
a  lamellar  structure,  the  individual  layers  pursuing  a  general  direction 
from  the  peritoneal  covering  downward  and  inward  toward  the  lining 
mucous  membrane.  The  principal  layers  are  in  turn  united  by  com- 
municating bundles,  so  that  when  separated  from  one  another  the  spaces 
between  them  have  a  rhomboidal  shape.  Very  nearly  the  same  ap- 
pearances are  obtained  when  the  section  is  transverse  or  oblique  as 
when  made  in  a  longitudinal  direction.  Over  the  larger  portion  of 
the  uterine  surface  the  peritonaeum  is  firmly  adherent.  Only  at  the 
lower  segment,  for  a  space  varying  from  three  to  six  centimetres, 
measured  from  the  internal  os,  the  peritoneal  attachment  is  easily 
separable.  According  to  Hofmeier,*  the  muscular  plates  in  this 
division  are  loosely  associated  together,  and  the  fibers  of  each  lamella 
are  intimately  interwoven,  crossing  one  another  in  every  direction.     In 

*  Cyclopaedia  of  Anatomy  and  Physiology,  article  Uterus  and  its  Appendages, 
p.  645. 

f  Vide  ScANZONi,  Handbuch  der  Geburtshiilfe,  p.  77. 

X  Vide  Spiegelberg,  Handbuch  der  Geburtshiilfe,  p.  51. 

»  Hofmeier,  Das  Unterer  Uterensegment  in  Schroeder's  Schwagnere  und  Kreiss- 
ende  Uterus,  p.  59. 


CHANGES  IN  THE  MATERNAL  ORGANISM  BY  PREGNANCY.  Y9 


the  body  proper  of  the  uterus  there 
is  a  broad  muscular  layer,  which  ad- 
heres firmly  to  the  peritoneal  covering, 
the  differentiation  of  the  individual 
lamellae  is  more  pronounced,  the  mus- 
cular fibers  are  arranged  more  in  bun- 
dles, and,  in  general,  form  layers  which 
correspond  to  a  greater  degree  to  the 
longitudinal  and  transverse  axes  of  the 
uterus. 

The  uterine  artery,  after  first  sup- 
plying a  branch  to  the  cervix,  runs  up 
along  the  side  of  the  uterus,  and  gives 
off  the  first  important  branch  to  the 
body  of  the  uterus  at  the  point  where 
the  peritonaeum  firmly  adheres  to  the 
muscular  walls.  The  lower  segment, 
therefore,  receives  no  important  vessels, 
and  is  characterized  by  a  low  degree 
of  vascularity.* 

With  the  growth  of  the  gravid 
uterus,  the  peritoneal  coat  is  put  upon 
the  stretch,  and,  in  places,  a  thicken- 
ing of  the  serous  membrane  lakes  place 
by  the  formation  of  new  tissue  ele- 
ments. At  the  same  time  the  folds 
of  the  broad  lip:aments  gradually  sepa- 
rate, so  that  toward  the  end  of  preg- 
nancy the  ovaries  and  Fallopian  tubes 
are  in  close  contact  with  the  uterus. 

The  growth  of  the  uterus  is  con- 
fined chiefly  to  the  body,  the  cervix 
participating  only  to  a  slight  extent. 
In  the  early  months,  the  increase  is 
rather  in  the  antero-posterior  and  lat- 
eral diameters  than  in  the  longitudinal 
diameter.  As  a  consequence,  in  the 
rule,  it  is  not  until  the  fourth  month 
that  the  fundus  can  be  felt  through 
the  abdominal  walls  above  the  sym- 
physis pubis.  In  these  earlier  months 
the  normal  anteflexion  of  the  uterus 
is  increased  by  the  weight  of  the  cor- 

*  HoFMEiER,  Beitrage  zur  Anatomie  der  Schwangeren  und  Kreissenden  Uterus, 
p.  33. 


O.i. 


O.e. 


Fig.  56.— Lower  segment  of  uterus,  sixth 
month  pregnancy.  iHofmeier.)  B, 
boundary  of  firm  peritoneal  attach- 
ment ;  O.  I.,  internal  orifice  ;  O.  e., 
external  orifice. 


80 


PHYSIOLOGY  OP  PREGNANCY. 


pus  uteri.  In  the  fifth  month  the  uterus  fills  the  hypogastrium,  and 
in  the  ninth  month  reaches  the  epigastrium.  During  the  last  two 
weeks,  however,  the  uterus  sinks  somewhat  into  the  pelvic  cavity.  At 
the  same  time  the  fundus  of  the  uterus  sinks  downward  and  forward, 
so  as  to  stand  about  three  inches  beneath  the  lower  extremity  of  the 
sternum. 

In  the  upright  posture  the  uterus,  in  advanced  pregnancy,  rests 
upon  the  anterior  abdominal  walls.  As,  in  the  intervals  of  contrac- 
tion, the  uterus  is  a  mere  sac  with  fluid  contents,  it  becomes  flattened 
from  front  to  rear,  and  the  width  increases  at  the  expense  of  the  dis- 
tance from  the  fundus  to  the  symphysis  pubis.  In  the  horizontal 
position,  in  which  the  uterus  rests  upon  the  vertebral  column,  its 
length  is,  on  the  contrary,  increased  and  its  width  diminisiied.  In 
the  upright  position,  the  intestines  occupy  the  space  posterior  to  the 
uterus.  In  the  dorsal  position,  the  intestines  lie  chiefly  upon  the 
sides,  but  partly,  too,  in  front  of  the  uterus. 

During  the  first  three  months  of  pregnancy  the  pyriform  shape  of 
the  uterus  is  preserved.  During  the  succeeding  three  months,  owing 
to  the  relative  increase  in  the  lateral  and  antero-posterior  diameters, 
the  body  gradually  assumes  the  appearance  of  a  flattened  spheroid. 
After  the  sixth  month  the  longitudinal  diameter  again  preponderates. 

As  the  dilatation  of  the  uterus  takes  place  more  rapidly  in  its  upper 
than  in  its  lower  segment,  the  cavity  of  the  organ  assumes,  under 
normal  conditions,  an  oval  shape,  with  the  narrow  end  pointing  down- 
ward, corresponding  to  the  ovoid  shape  of  the  foetus  in  head-presenta- 
tions. It  was  long  taught  and  believed  that  this  change  of  shape, 
occurring  in  the  later  months  of  pregnancy,  was  due  to  the  gradual 
unfolding  of  the  cervix  uteri  from  above  downward,  which  thus  con- 
tributed to  the  enlargement  of  the  uterine  cavity.  It  is,  however, 
probable  that,  with  rare  exceptions,  the  cervix  uteri  maintains  its  com- 
plete integrity  up  to  the  commencement  of  labor.  The  enlargement 
of  the  uterus,  necessitated  by  the  development  of  the  foetus,  results 
chiefly  from  the  growth  and  distention  of  the  fundus  and  posterior 
uterine  wall. 

The  cervix  uteri  participates  in  the  hypertrophy  of  the  entire 
uterus.  Its  development,  however,  is  completed  by  the  fourth  month, 
and  is  the  result  not  so  much  of  increased  growth  or  new  formation  of 
tissue  elements  as  of  the  loosening  of  its  structure  and  swelling  from 
serous  infiltration.  This  latter  is  the  consequence  of  a  hyperaemia  of 
the  cervix,  which  results  from  the  passive  relaxation  and  dilatation  of 
the  cervical  vessels.  It  occasions  a  physiological  softening  of  the 
tissues,  which  first  manifests  itself  in  those  portions  of  the  cervix  where 
the  least  resistance  is  encountered,  viz.,  beneath  the  mucous  mem- 
brane beginning  at  the  os  externum,  extending  outward  through  the 
muscular   structures   of  the   vaginal  portion,  and   afterward   upward 


CHANGES  IN  THE  MATERNAL  ORGANISM  BY  PREGNANCY,  si 

toward  the  os  iuteruuin.*  The  follicles  of  the  cervical  mucous  mem- 
brane furnish  a  thickened  secretion,  which  fills  the  cervical  canal, 
and  forms  what  is  known  as  the  "  mucous  plug."  Frequently  the 
orifices  of  the  follicles  become  occluded.  The  follicular  sacs  then  fill 
with  their  own  secretion,  and  project  from  the  mucous  surface  as  the 
ovules  of  Naboth.  Erosions  about  the  os  externum  are  rarely  absent 
in  advanced  pregnancy. 

With  the  advance  of  pregiumcy  an  apparent  shortening  of  the  cer- 
vix takes  place,  at  first  confined  to  the  vaginal  portion,  but  afterward 
involving  the  entire  organ.  The  earlier  explanation  of  this  phenomenon, 
and  one  which  still  nK?ets  with  very  general  acceptance,  assumes  that, 
after  the  sixth  month,  a  gradual  unfolding  of  the  cervix  from  above 
downward  takes  place,  which  contributes  to  the  enlargement  of  the 
uterine  cavity.  In  this  manner  space  is  provided  in  correspondence 
with  the  rapidly  increasing  growth  of  the  foetus.  The  strength  of 
this  doctrine  lay,  in  a  great  measure,  in  the  seemingly  confirmatory 
evidence  afforded  by  digital  explorations. 

In  opposition  to  the  current  opinion,  Stoltz,  in  his  inaugural  thesis, 
published  in  182(!,f  maintained  that  the  internal  os  remained  closed  up 
to  the  last  two  weeks  ])receding  delivery,  when,  indeed,  under  the  in- 
fluence of  painless  contractions,  the  effacement  of  the  cervix,  described 
by  earlier  writers,  did  in  fact,  at  least  in  primipara?,  take  place.  Stoltz 
explained  the  ai)jiarent  shortening  of  the  cervix  as  the  result  of  a 
spindle-shaped  dilatation  of  the  cervical  canal,  causing  an  approxima- 
tion of  the  external  and  internal  orifices.  In  1859  Duncan;];  furnished 
corroborative  evidence  of  the  general  correctness  of  Stoltz's  view,  by 
means  of  two  dissections  of  uteri  derived  from  women  who  died  re- 
spectively in  the  seventh  and  eighth  months  of  pregnancy.  In  these 
cases  the  length  of  the  cervix  uteri  had  undergone  little  or  no  change 
consequent  upon  pregnancy.  Duncan,  however,  in  common  with 
Stoltz,  admitted  that,  during  the  later  days  of  gestation,  incipient 
uterine  contractions  of  a  painless  nature  may  lead  to  the  opening  of 
the  internal  os.  In  1803  he  showed  that  Stoltz's  discovery  had  been 
anticipated  by  Weitbrecht  in  1750.*  In  1862  Professor  I.  E.  Taylor,  || 
of  New  York,  stated,  what  is  without  doubt  true  in  the  majority  of 
cases,  that  the  cervix  remained  closed,  and  retained  its  entire  length  up 
to  the  very  beginning  of  active  labor.  In  evidence  he  offered  the  re- 
sults of  four  post-mortem  examinations  made  upon  women  dying  from 

*  LoTT,  Zur  Anatomie  und   Physiologic  des  Cervix  Uteri,  Erlangen,  1872,  pp. 
35,  36. 

t  Sur  les  dififerents  etats  du  col  de  I'literus,  niais  principaleinent  sur  les  change- 
ments  que  la  gestation  et  raccoucheinent  lui  font  eprouver,  Strasbourg,  183G. 

t  On  the  Cervix  Uteri  in  Pregnancy,  Edinburgh  Med.  Jour.,  vol.  iv,  1859,  p.  774. 

*  Vide  Edinburgh  Med.  Jour.,  September.  1863. 

1  Taylob,  On  the  Cervix  Uteri,  Am.  Med.  Times,  June  21,  1862. 
6 


g2  PHYSIOLOGY   OP  PREGNANCY. 

accidental  causes  during  the  first  stage  of  labor.*  In  1873  I  found  in 
the  dissecting-room  a  woman  seven  months  pregnant,  who  had  died 
in  the  first  stage  of  labor,  but  after  dilatation  of  the  cervix  had  well 
advanced.  The  bag  of  waters,  in  the  form  of  a  cylindrical  sac  two 
inches  in  diameter,  protruded  into  the  vagina.  Both  the  cervical 
orifices  were  distinctly  defined;  the  cervix  was  equally  expanded 
tliroughout  its  entire  extent ;  and  tlie  head  rested  above  the  os  inter- 
num. The  cervix  clearly  formed  no  part  of  the  uterine  cavity,  but 
served  merely  as  a  communicating  passage  between  the  uterus  and 
vao-ina.  Dr.  Taylor  has  made  some  very  interesting  observations  upon 
the  action  of  tlie  cervix  during  labor,  using  for  the  purpose  a  large 
(three  to  three  and  a  half  inch)  cylindrical  speculum,  by  means  of 
which  the  entire  process  can  be  freely  witnessed.  In  multiparous 
women  he  has  seen  the  head  descend  during  a  pain  so  as  to  produce 
complete  obliteration  of  the  cervix,  and  then  recede,  leaving  the  latter 
with  the  same  appearances  as  existed  previous  to  labor,  f 

While  the  non-shortening  of  the  cervix  has  been  fairly  demon- 
strated, it  is  not  so  clear  tluit  the  os  internum  remains  closed  in  all 
cases  up  to  the  beginning  of  labor.  Certainly  there  are  rare  excep- 
tions to  the  rule,  Litzmann  J  reported  a  case  in  which  the  mem- 
branes were  found,  at  the  time  of  labor,  attached  to  the  cervical  wall 
around  the  periphery  of  the  os  externum.  In  a  few  instances  I  have 
had  an  opportunity,  during  the  last  period  of  pregnancy,  to  deter- 
mine by  touch  the  dilatation  of  the  os  internum.  The  cervix,  how- 
ever, did  not  expand  in  such  a  way  as  to  become  continuous  with  the 
uterine  cavity,  but  remained  distinct  and  apart,  preserving  its  inde- 
pendent existence.  IIow  far  such  a  dilatation  is  due  to  painless  labor 
it  is  impossible  to  say.  Miiller  *  regards  it  rather  as  the  result  of  the 
pressure  of  the  head  upon  the  softened  cervix.  I  had  once  occasion 
to  examine  a  multipara  toward  the  end  of  gestation,  to  determine  the 
question  as  to  the  safety  of  her  making  a  railroad  journey  to  a  neigh- 
boring city.  I  found  the  head  low,  the  cervix  soft,  and  the  os  inter- 
num clearly  dilated  to  the  size  of  a  dollar.  Two  weeks  later  I  was 
called  to  see  her  in  the  early  stage  of  labor,  and  found  that,  under  the 
influence  of  the  uterine  contractions,  the  canal  of  the  cervix  had  again 
closed. 

The  apparent  shortening  of  the  cervix  is  unquestiona])ly  due  in 
part  to  the  swelling,  incident  to  pregnancy,  of  the  vaginal  mucous 

*  Vide  likewise  the  ease  of  Angus  McDonald,  in  Edinburgh  Med.  Jour.,  April,  1877. 
\  Med.  Record,  October  13,  1877. 

X  Das  Verhalten  des  Cervix  Uteri  in  der  Schwangerschaft,  Arch.  f.  Gynaek.,  Bd. 
X,  p.  130. 

*  Untersuchungen  iiber  die  Verklirzung  der  Vaginalportion  in  den  letzten 
Monaten  der  Graviditat :  Scanzoni's  Beitrage,  Bd.  v,  H.  2,  1869.  pp.  306  et  seq. 
Muller  does  not,  however,  exclude  the  possible  action  of  uterine  contractions. 


CHANGES  IN  THE  MATERNAL  ORGANISM  BY  PREGNANCY. 


83 


membrane,  and  of  the  vascular,  loose-meshed  tissues  surrounding  the 
cervix  at  the  vaginal  junction.  But,  in  addition,  a  noticeable  differ- 
ence may  be  observed  between  cases  in  which  the  head  occupies  the 
pelvis  and  tliose  in  which  it  rests  upon  an  iliac  fossa.  In  the  latter  the 
cervix  is  found,  both  by  the  speculum  and  by  the  touch,  to  have  pre- 
served its  entire  length.  In  the  former,  on  the  contrary,  the  anterior 
lip  is  often  obliterated,  while  the  length  of  the  canal  and  the  posterior 
cervical  wall  remain  unchanged. 

In  explanation  of  this  phenomenon,  it  is  to  be  borne  in  mind  that 
in  the  upright  position  the  uterus  forms  with  the  horizon  an  angle  of 
thirty-five  degrees.  The  weight  of  the  ovum,  resting  upon  the  in- 
clined plane  of  the  ixterus,  increases  the  convexity  of  the  anterior  wall, 
and  the  head  of  the  foetus,  when  it  enters  the  pelvic  cavity,  does  not 
fall  directly  upon  the  os  internum,  but  somewhat  in  front,  producing, 


Fig.  57.— B,  borders  of  the  cervical  mucous  membrane  ;  PI,  placenta  ;  V,  bladder  :  O.i.,  os  in 
ternum  ;  O.e.,  os  externum  ;  A  a',  apparent  length  of  cervical  canal  on  digital  examination 

in  accordance  with  the  laws  of  gravity,  a  bulging  of  the  anterior  lower 
segment.  TTpon  vaginal  examination  the  head  is  felt,  therefore,  low 
down,  and  covered  by  the  uterine  walls,  while  the  cervix  is  drawn  up- 
ward and  backward  by  the  retractor  muscles,  and  is  often  reached 
with  difficulty,  because  the  finger,  in  passing  to  it,  has  first  to  make 
the  circuit  of  the  child's  head.  The  bulging  produced  by  the  latter 
effaces  the  angle  between  the  anterior  lip  and  the  vaginal  wall,  while 
the  posterior  lip  remains  unchanged.     The  canal  of  the  cervix  assumes 


g^  PHYSIOLOGY  OF  PREGNANCY. 

an  oblique  or  nearly  vertical  direction,  but  when  examined  with  care, 
with  due  regard  to  the  physiological  softening  of  its  tissues,  is  found 
to  have  preserved  its  normal  length.  By  pushing  the  head  away  from 
the  cervix,  or  by  placing  the  patient  in  the  knee-elbow  position,  so  as 
to  allow  the  head  to  recede,  the  anterior  lip  resumes  its  normal  dimen- 
sions.* 

Bandl  (Ueber  das  Verhalten  des  Uterus  und  Cervix  in  der  Schwangerschaft 
und  wahrend  der  Geburt,  1876)  has  sought  to  prove  that  whereas,  in  point  of 
fact,  a  portion  of  the  cervix  remains  closed  to  the  end  of  ])regnancv,  a  portion  of 
the  same  does,  as  Roederer  tauglit,  contribute  to  the  formation  of  the  uterine 
cavity. 

In  presenting  his  views  to  the  Naturforscher-Versammlung  at  Hamburg,  in 
1876,  Bandl  stated  that,  upon  examination  of  the  familiar  Braune  section, 
made  upon  the  cadaver  of  a  parturient  woman,  he  was  struck  with  the  impossi- 
bility that  the  cervix  therein  depicted,  measuring  eleven  centimetres  in  front  and 
ten  centimetres  posteriorly,  could  be  the  sliort  narrow  canal,  from  two  to  four 
centimetres  long,  observed  by  Miiller  toward  the  end  of  gestation.  As  a  rule, 
however,  in  case  of  the  deep  position  of  the  ovum,  or  fetal  head,  above  the 
constriction  designated  by  Mtiller  as  the  os  internum,  may  be  felt  a  second  and 
much  larger  ring,  which  his  subsequent  investigations  showed  was  the  os 
internum  proper.  The  lower  constriction  he  termed,  therefore,  the  spurious  os 
internum,  or  the  ring  of  Miiller.  Owing  to  the  fact  that  the  walls  of  tlie  canal 
between  the  upper  and  lower  rings  are  much  thinner  than  those  of  the  uterine 
body,  a  well-defined  ridge  is  felt,  which  has  since  been  termed  the.ju.ntr  <jf 
Bandl. 

At  first  Bandl  supposed  that  the  new  cervico- uterine  canal  was  covered  by 
decidua,  the  mucous  membrane  jjioper  having  been  crowded  downward  by  the 
pressure  of  the  ovum.  In  this  way,  by  the  formation  of  overla])j)ing  folds,  the 
ring  of  Muller  is  approximated  to  the  os  externum,  and  the  apparent  shortening 
of  the  cervix  is  accomplished.  At  the  same  time,  by  the  continued  growth, 
and  by  what  he  termed  the  vital  action  of  the  parts,  a  "new  cervix "  was 
formed  above  the  remains  of  the  old  canal,  derived  chiefly  by  a  sort  of  migra- 
tory movement  from  the  nuiscular  structure  of  the  original  cervix.  The 
decidua,  meantime,  unable  to  follow  the  expansion  of  the  outer  layers,  was  torn 
in  many  places,  forming  scattered  islets,  between  which  the  chorion  came  into 
immediate  contact  with  the  muscular  walls. 

In  September,  1877,  at  a  meeting  of  the  German  gynaecologists  at  Munich, 
Bandl  abandoned  his  theory  of  a  new  cervix  formed  by  a  movement  u])ward  of 
musculai-  fibers  and  the  crowding  down  of  the  cervical  nmcous  membiane,  and 
taught  in  its  place  that,  in  primiparai,  a  portion  of  the  cervix  really  exjjands  to 
contribute  to  the  uterine  cavity.  In  the  earlier  months,  he  stated,  the  mucous 
membrane  of  this  portion  retains  its  cervical  characteristics,  but  in  the  latter 
part  of  gestation  it  is  converted  into  a  kind  of  decidua.  The  flattened,  ex- 
panded portion  in  multiparae,    he  acknowledged,  was  often  extremely  small. 

*  P.  MULLKR,  op.  pit.,  p.  ,343. 

LoTT,  Verhalten  des  Cervix  Uteri  wahrend  der  Schwangerschaft,  p.  71. 

I.  E.  Taylor,  Non-shortening  of  the  Cervix  during  Gestation,  Med.  Record, 
October  13,  1877,  p.  646,  with  verbal  statement  of  the  author  concerning  the  results 
of  his  examinations  of  pregnant  women  in  the  genu-pectoral  position. 


CHANGES  IN   THE    MATERNAL  ORGANISM  BY  PREGNANCY, 


85 


This,  at  first,  he  attributed  to  morbid  conditions,  such  as  slight  inflamma- 
tions, or  defective  invoUition,  which  interfered  with  the  rolling  out  of  the 
ujjper  portion  of  the  canal.  In  1879,  before  the  Natur.-Versammlung  at 
Baden-Baden,  he  explains  finally  that,  in  first  labors,  the  mucous  membrane  of 
the  dilated  portion  of  the  cervix  becomes  torn  and  stripped  off.  Subsequently 
a  new  membrane  is  formed  upon  the  denuded  surface  which  is  not  distinguish- 
able from  that  of  the  uterine  body,  and  upon  which,  in  future  pregnancies, 
the  decidual  formation  may  be  traced  to  the  persistent  portion  of  the  canal. 
The  OS  internum,  according  to  this  view,  is  not  marked  by  the  cervical  mucous 
membrane,  but  is  situated  in  the  muscular  walls,  and  usually  corresponds  to  the 
point  at  which  the  peritonaium  leaves  the  uterus. 

Kustner  (Beitrage  zur  Anatomic  der  Cervix  Uteri,  Arch.  f.  Gynaek.,  vol. 
xii,  p.  383)  and  Marchand  (Noch  Einmal  das  Verhalten  der  Cervix  Uteri  in  der 
Schwangerschaft,  Arch.  f.  Gynaek.,  vol.  xv,  p.  169)  claimed  in  certain  cases 
to  have  found  the  \Aicx  palmatse  and  cylindrical  epithelial  cells  at  the  distance 
of  from  two  to  two  and  a  half  centimetres  from  the  internal  os,  showing  that  a 
funnel-shaped  expansion  of  the  upper  portion  of  the  cervix  does  take  place 
during  pregnancy.  Further  evidence  in  support  of  Ktistner's  views  has  been 
offered  by  Keilmana  (Zur  Klarung  der  Cervixfrage,  Zeitschr.  f.  Geburtshlilfe 
und  Gynaek.,  vol.  xxii,  p.  106)  derived  from  observations  made  upon  the  uteri 
of  gravid  bats. 

Bayer  (Gynaekologische  Klinik,  von  Freund,  Art.  Morphologic  der  Gebar- 
mutter,  1885),  in  an  extremely  complicated  account  of  the  muscular  structure 
of  the  uterus,  maintains,  likewise,  that  the  lower  segment  is  produced  by  the 
rolling  out  of  the  upper  part  of  the  cervix,  and  that  the  cervical  mucous  mem- 
brane is  converted  into  decidua.  He  regards  the  process  as  a  temporary  pro- 
vision, which  disappears  with  pregnancy.  The  constriction  termed  by  Bandl 
the  ring  of  Mtiller,  Bayer  maintains,  is  not  an  accidental  point  in  the  cervix, 
but  is  the  result  of  the  loop-like  arrangement  of  fibers  derived  from  the  re- 
tractor muscles,  by  which  the  continuance  of  the  cervical  eversion  is  arrested  at 
a  definite  point  in  the  canal. 

According  to  investigations  made  by  Leopold,  McDonald,  Miiller, 
Sanger,  Schroeder,  Hofmcier,  Waldeyer,  myself,  and  others,  the  lower 
segment  is  derived  from  the  body  of  the  uterus,  and  not  from  the  cer- 
vix. In  three  autopsies  made  by  me  upon  women  who  had  died  in  the 
last  month  of  pregnancy — one  primipara  and  two  multiparae — the  same 
conditions  prevailed  in  all,  viz.,  the  cervix  exceeded  four  centimetres 
in  length  and  was  increased  in  thickness,  the  mucous  plug  terminated 
at  the  upper  orifice,  and  the  membranes  adhered  closely  to  the  lower 
segment  and  to  the  borders  of  the  internal  orifice.  That  the  cervix 
maintains  its  independence  to  the  beginning  of  labor  is  therefore  true 
in  very  many  instances.  That  there  are  no  exceptions,  it  would  be 
hazardous  to  maintain  in  the  face  of  the  positive  testimony  of  Bandl, 
Marchand,  and  Bayer. 

In  the  vagina  changes  take  place  corresponding  to  those  in  the 
uterus,  though,  of  course,  less  in  degree.  The  smooth  muscular  fibers 
hypertrophy ;  the  vessels  of  the  venous  plexus  increase  in  size,  and  im- 
part a  blue  color  to  the  vaginal  walls ;  the  mucous  membrane  becomes 


gg  PHYSIOLOGY  OF   PREGNANCY. 

thickened,  and  furnishes  a  more  abundant  secretion.  The  mucous 
membrane  likewise  increases  in  length,  so  that,  in  spite  of  the  fact  that 
it  is  lifted  upward  by  the  elevation  of  the  uterus,  the  anterior  vaginal 


Fia.  58. — Utenis  from  a  multipara  who  died  in  the  last  month  of  pretrnanoy,  showing:  cervix  of 
normal  length  with  membranes  adherent  to  the  os  internum.     (Bellevue  Hospital.) 

wall  not  unfrequently  protrudes  from  the  vulva.  The  papillae  swell, 
and  impart  a  granular  feel  to  the  finger. 

The  vulva  becomes  turgescent,  the  labia  gape  apart,  to  the  mucous 
surface  the  enlargement  of  the  veins  and  venous  plexuses  gives  a  dusky 
hue,  and  the  follicles  secrete  abundantly. 

The  connective  tissue  between  the  layers  of  the  broad  ligaments  and 
around  the  uterus  becomes  succulent  from  serous  infiltration.  The 
lymphatics,  which  convey  away  the  waste  engendered  by  the  rapid  tis- 
sue-changes in  the  pelvic  organs,  enlarge  in  conformity  with  the  in- 
creased labor  thrown  upon  them.  The  hii)s  broaden  from  the  deposit 
of  fat  in  the  subcutaneous  tissue  of  the  entire  pelvic  region. 

With  the  growth  of  the  uterus  the  abdominal  walls  are  put  upon 


CHANGES  IN  THE  MATERNAL  ORGANISM  BY  PREGNANCY.  §7 

the  stretch,  and,  in  well-nourislied  individuals,  are  increased  in  thick- 
ness by  the  more  abundant  formation  of  adipose  tissue.  By  the  fifth 
montJi  the  navel  begins  to  diminish  in  depth,  and  about  the  seventh 
month  becomes  level  with  the  skin.  During  the  last  two  months  the 
navel  often  is  everted  by  the  pressure  of  the  uterine  tumor,  and  forms 
a  rounded  elevation.  Another  consequence  of  the  stretchino-  of  the 
abdominal  walls  is  the  formation  of  reddish,  bluish,  and  at  times  of 
white  glistening  streaks  (stria^),  which  do  not  disappear  after  delivery, 
though  they  lose  their  coloring.  They  rarely  fail  in  the  last  third  of 
pregnancy.  They  are  found  most  abundant  upon  the  lower  half  of  the 
abdomen,  especially  upon  the  sides,  where  they  form  curved,  sinuous 
lines.  They  are  due  to  an  atrophic  condition  of  all  the  skin-layers, 
to  partial  obliteration  of  the  lymph-spaces,  and  to  a  condensation  of 
the  connective- tissue  elements,  which,  in  place  of  forming  rhomboid 
meshes,  run  parallel  to  one  another.*  Stria?  are  produced  likewise  in 
pathological  distentions  of  the  abdomen,  and  are  not  peculiar  to  preg- 
nancy. Similar  streaks  form  upon  the  nates  and  upon  the  anterior 
and  posterior  surfaces  of  the  thighs.  They  may  occur,  too,  independ- 
ent of  pregnancy,  as  in  the  ra])id  development  of  the  hips  at  puberty. 
Painful  sensations  at  the  costal  insertions  of  the  abdominal  muscles 
are  often  experienced  during  pregnancy.  They  occur  more  commonly 
in  multiparse,  and,  owing  to  the  preponderance  of  the  right  lateral 
position  of  the  uterus,  with  greater  frequency  upon  the  right  side. 
Sometimes  the  recti  muscles  are  separated  from  one  another.  This  is 
specially  liable  to  take  place  in  contracted  pelves,  and  in  women  of 
small  stature,  in  whom,  on  account  of  the  insufficient  longitudinal 
diameter  of  the  abdominal  cavity,  the  uterus  is  forced  to  make  for  itself 
the  space  requisite  for  its  development  to  term  at  the  expense  of  the 
abdominal  walls. 

The  mammary  glands,  previous  to  gestation,  are  firm  and  nearly 
hemispherical.  During  pregnancy  the  breasts  increase  in  volume,  and 
present  characteristic  changes  in  structure  and  consistence.  These 
changes  are  due  to  a  swelling  of  the  connective  tissue  of  the  organ,  the 
development  of  glandular  acini  along  the  course  of  the  lactiferous  ducts, 
and  the  increased  deposition  of  fat  between  the  lobes.  The  enlarge- 
ment of  the  breast  often  begins  in  the  second  month,  and  becomes  no- 
ticeable between  the  fourth  and  fifth  months  of  gestation.  With  the 
development  of  the  glandular  structure  the  breasts  possess  a  knotty, 
uneven  feel,  more  marked  at  first  about  the  periphery  of  the  organ,  and 
thence  proceeding  gradually  toward  the  nipple.  The  veins  enlarge, 
and  form  a  tracery  beneath  the  skin.  Early  in  pregnancy,  fullness  of 
the  breasts,  and  pains,  shooting  toward  the  axilla,  are  often  experienced. 
As  the  breasts  increase  in  size,  the  cutis  yields  in  many  women  about 

*  BusEY,  The  Cicatrices  of  Pregnancy,  Trans,  of  the  Am.  Gynicc.  Soc,  vol.  iv, 
p.  141. 


gg  PHYSIOLOGY   OF   PREGNANCY. 

the  periphery,  where  the  tension  is  greatest,  whereby  bhiish,  white,  or 
reddish  lines,  like  those  remarked  ui)on  the  abdomen  and  thighs,  make 
their  appearance. 

The  nipple  becomes  elongated,  is  more  sensitive,  and  enters  readily 
into  an  erectile  condition.  Changes  in  the  areola  are  jnstly  regarded 
as  among  the  most  important  evidences  of  the  existence  of  pregnancy. 
Often  as  early  as  the  second  month  the  areola  has  a  soft,  anlematous 
feel,  and  is  raised  above  the  level  of  the  surrounding  skin.  The  seba- 
ceous follicles,  ten  to  twenty  in  number,  enlarge,  and  bedew  the  surface 
with  moisture.  By  the  middle  of  pregnancy  a  circle,  due  to  pigment-, 
ary  deposit,  is  formed  around  the  nipple,  the  coloration  of  which  de- 
pends in  part,  though  not  altogether,  upon  the  complexion  of  the 
individual,  being  usually  more  intense  in  brunettes  than  in  women 
with  fair  hair  and  delicate  skins.  In  the  negress  the  areola  is  jet- 
black,  while  in  the  albino  it  is  of  a  delicate  rose-color  (Montgomery). 
The  diameter  of  the  pigmented  circle  averages  from  an  inch  to  an  inch 
and  a  half,  though  it  sometimes  greatly  exceeds  the  figures  mentioned. 
In  the  latter  part  of  pregnancy  there  often  forms  around  the  outer  part 
of  the  areola  a  so-called  secondary  areola,  consisting  of  scattered  round 
spots,  presenting  the  appearance  as  though,  to  use  the  language  of 
Montgomery,  the  color  had  been  discharged  by  a  shower  of  drops. 
This  peculiarity  is  due,  for  the  most  part,  to  the  presence  of  enlarged, 
non-pigmented  sebaceous  follicles. 

The  pressure  of  the  gravid  uterus  gives  rise  to  functional  disturb- 
ances in  the  neighboring  organs  of  the  pelvic  cavity.  The  capacity 
of  the  bladder  is  diminished,  and,  as  a  consequence,  increased  fre- 
quency of  urination  results.  In  some  women,  when  the  bladder  is 
moderately  full,  the  mere  act  of  coughing  or  sneezing,  or  the  up- 
right posture,  produces  involuntary  discharges  of  water.  Constipa- 
tion is  common,  due  not  so  much,  however,  to  mechanical  obstruction 
as  to  diminished  intestinal  action.  In  the  later  months  of  })regnaiu;y, 
pressure  on  the  sacral  nerves  gives  rise  at  times  to  numbness  of  the 
extremities,  neuralgic  pains,  cramps,  and  hindered  locomotion.  (Ede- 
ma of  the  lower  half  of  the  body  and  varicose  dilatation  of  the  veins 
of  the  legs,  the  rectum,  and  vulva,  are  referable  partly  to  pressure  and 
partly  to  the  increased  vascular  fullness  of  the  pelvic  vessels  induced 
by  pregnancy. 

Changes  effected  in  the  Entire  Organism. 

Corresponding  to  the  enormous  development  of  the  vascular  ap- 
paratus in  the  gravid  uterus,  there  is  an  increase  in  the  total  quantity 
of  blood  in  the  circulation.*     Andral   and    Gavarret,    Regnault   and 

*  This  assertion,  which  is  simply  the  formal  statement  of  a  physiological 
necessity,  has  been  experimentally  proved  to  be  correct  in  bitches  by  Spiegelberg  and 


CHANGES  IN  THE   MATERNAL  ORGANISM  BY  PREGNANCY. 


89 


Becquerel  and  Kodier,  maintained  that  in  pregnancy  the  blood  was 
serous  in  character.  This  view  was  sustained  apparently  by  the 
later  investigations  of  Nasse,  Spiegelberg,  Gscheidlin,  Ingerslev,  and 
Meyer.  It  is  unquestionable  that  in  early  pregnancy  a  hydrtemic 
condition  develops  in  many  women,  consequent  upon  the  demands 
made  upon  tlie  maternal  system  by  the  growing  foetus,  and  upon  the 
increased  tissue  waste  when  these  conditions  are  associated  with  a 
diminished  capacity  to  take  and  assimilate  food ;  but  with  improved 
methods  of  examination  it  has  been  demonstrated  by  Fehlinf,  Rein, 
and  Richard  Schroeder  that,  in  advanced  pregnancy,  both  the  haemo- 
globin and  the  total  number  of  red  blood-corpuscles,  are  in  the  rule, 
augmented.* 

As  a  necessary  corollary  to  the  increase  of  the  total  blood-supply  in 
pregnant  women,  the  maintenance  of  the  circulation  would  seem  to 
require  either  greater  frequency  in  the  contractions  of  the  heart,  or 
that  the  entire  quantity  of  blood  entering  the  ventricles  during  the 
diastole  should  be  increased.  Kehrer  maintains  that  the  frequency  of 
the  pulsations  of  the  heart  exceeds  eighty  to  the  minute.  Larcher  f 
and  other  French  investigators  assert  that  the  interposition  of  the  en- 
larged and  multiplied  vascular  channels  in  the  pelvic  organs  increases 
the  labor  thrown  upon  the  heart,  in  response  to  which  an  eccentric 
hypertrophy  of  the  left  ventricle  takes  place,  but  the  evidence  on  this 
point  is  conflicting. 

Pregnancy  increases  the  size  of  the  thyroid  gland.  In  districts 
where  goitre  is  endemic,  and  in  women  in  whom  a  predisposition  al- 
ready exists,  pregnancy  may  produce  a  temporary  form  of  the  disease, 
or  furnish  the  starting-point  of  the  permanent  affection. J 

In  rather  more  than  half  the  cases  of  pregnancy,  thin  bone-like 
lamellae,  consisting  chiefly  of  phosphate  and  carbonate  of  lime,  meas- 
uring from  one  sixth  to  one  half  a  line  in  thickness,  are  found  de- 
posited upon  the  inner  surface  of  the  skull.  These  plates  have  been 
termed  osteophytes  by  Rokitansky.  They  occur  after  the  third  month, 
and  are  found  chiefly  upon  the  frontal  and  parietal  bones,  especially 
along  the  course  of  the  sulcus  falciformis  and  the  arteria  meningea 
media* 

We  have  already  noticed  the  increase  in  the  carbonic  acid  discharged 

Gscheidlin.  Vide  Untersuchungen  iiber  die  Blutraenge  traehtiger  Hiinde,  Arch.  £. 
Gynaek.,  Bd.  iv,  p.  112. 

*  Vide  Schroeder,  Untersuchungen  ueber  die  Beschaffenheit  des  Blutes  von 
Schwangeren  und  Wochnerinnen,  etc.,  Arch.  f.  Gynaek.,  vol.  xxxix,  p.  306. 

f  Vide  Joulin,  Traite  complet  d'accouchement,  p.  383. 

X  L.  Tait,  Enlargement  of  the  Thyroid  Body,  Obstet.  Jour,  of  Gr.  Brit,  and  Ire., 
June,  1875. 

«  F6RSTER,  Handbuch  der  patholog.  Anat.,  Bd.  ii,  p.  945.  These  osteophytes 
are  not  peculiar  to  pregnancy  ;  they  likewise  occur  commonly  in  consumptives. 
Nouveau  Diet,  de  Chir.  et  de  Med.,  t.  xvii.  Art,  Grossesse. 


90 


PHYSIOLOGY  OF  PREGNANCY. 


by  the  lungs  during  pregnancy.  Andral  and  Gavarret  found  the  mean 
consumption  of  carbon  hourly  in  pregnant  women  equaled  8  grammes 
instead  of  6-4  grammes,  as  in  menstruating  women.  The  thorax  is 
increased  in  breadth  and  diminished  in  depth,  a  condition  which 
becomes  reversed  after  delivery.  There  is  usually,  toward  the  end  at 
least,  a  diminution  in  the  vital  capacitv  of  the  lungs.*  Subjectively, 
there  is  of  ten  experienced,  especially  in  primipara?,  a  sense  of  oppressed 
respiration  during  the  later  months  of  pregnancy.  This  feeling  is 
relieved,  however,  to  a  considerable  extent  when  the  uterus,  in  the 
last  two  to  three  weeks  of  pregnancy,  sinks  downward  and  forward. 

Very  few  pregnant  women  escape  altogether  troubles  of  digestion  ; 
of  these  the  most  common  are  nausea  and  vomiting,  due  to  spasmodic 
contractions  of  the  stomach  and  diaphragm.  The  nausea  and  vomit- 
ing usually  occur  on  waking  in  the  morning,  i.  e.,  with  an  empty 
stomach,  more  rarely  after  meals.  In  a  few  cases,  these  gastric  dis- 
turbances take  place  only  three  or  four  times  in  the  beginning  of 
pregnancv,  upon  the  first  suppression  of  the  menses.  Usually,  how- 
ever, they  recur  daily  during  the  first  three  months,  and  then  gradu- 
ally disappear.  In  the  early  period  of  pregnancy,  the  appetite  is,  as 
a  rule,  capricious,  like  that  of  chlorotic  women.  Some  are  said  to 
crave  unusual  and  even  disgusting  articles  of  food  (longings).  An 
increased  secretion  of  the  salivary  glands  is  often  a  noticeable  symptom. 
The  bowels  are  more  commonly  constipated.  In  a  few,  however,  diar- 
rh(jea  takes  place,  often  about  the  time  of  the  month  when  the  woman 
would,  if  not  pregnant,  have  her  menstrual  flow. 

It  is  not  surprising  that  in  the  first  three  months  of  pregnancy 
many  women  lose  their  flesh  and  color,  have  dark  circles  about  their 
eyes,  and  wear  a  drawn,  haggard  look  ;  but  after  the  third  month,  or 
later,  after  fetal  movements  have  been  felt,  the  appetite  returns,  the 
digestion  becomes  more  active,  the  nutrition  is  improved,  and  an  in- 
crease of  weight  in  normal  cases  takes  place,  which  can  not  be  accounted 
for  simply  by  the  growth  of  the  ovum.  According  to  Gassner's  esti- 
mates, the  average  gain  in  the  eight  months  amounts  to  five  and  a  half 
pounds,  in  the  ninth  month  to  three  and  a  half  pounds,  and  in  the  tenth 
month  to  about  three  and  a  quarter  pounds.  The  total  increase  he 
found  not  far  from  one  thirteenth  of  the  entire  weight  of  the  body.f 

We  have  already  noticed  the  pigmentation  of  the  areola  in  speaking 
of  the  changes  produced  in  the  breasts  of  pregnancy.     The  forehead 

*  Dohrn  found  that  in  sixty  per  cent  there  was  a  marked  diminution  in  the  vital 
capacity  of  the  kings  of  women  in  the  latter  part  of  pregnancy,  as  compared  with 
that  of  the  same  women  tested  twelve  to  fourteen  days  after  delivery.  Zur 
Kenntniss  des  Einflusses  von  Schwangerschaft  und  Wochenbett  auf  die  vitale 
Capacitat  der  Lungen,  Monatsschr.  f.  Geburtsk.,  Bd.  xxviii,  1866,  p.  457.  Earlier 
observations,  not  entirely  in  accord  with  those  of  Dohrn,  were  made  by  Fabius  and 
Wintrich.      Vide  Spiegelberg,  Lehrbuch  der  Geburtshulfe,  1877,  p.  63. 

f  Monatsschr.  f.  Geburtsk.,  Bd.  xix,  p.  1. 


THE   DIAGNOSIS   OF   PREGNANCY.  o^^ 

likewise  at  times  becomes  covered  with  dirty-looking  brownish  patches 
which  may  extend  over  tlie  entire  face,  especially  over  the  eyelids,  the 
root  of  the  nose,  and  the  upper  lip.  These  sjiots,  with  the  disfigure- 
ment they  occasion,  rarely  remain  permanent,  l)ut,  as  a  rule,  disap- 
pear shortly  after  confinement.  Similar  discolorations  are  often  ob- 
served about  the  external  organs  of  generation,  upon  the  abdomen, 
and,  with  considerable  constancy,  along  the  linea  alba  and  around  the 
umbilicus. 

Owing  to  the  hydraemic  condition  which  exists  during  pregnancy, 
the  urine  is  more  abundant  and  watery.  Albumen  in  the  urine  is  not 
an  infrequent  occurrence,  due,  probably,  in  the  milder  cases,  to  transi- 
tory catarrhal  affections  of  the  bladder.* 

The  nervous  system  becomes  more  impressionable.  The  whole 
character  frequently  undergoes  a  change.  The  most  amiable  of  women 
are  liable  to  become  fretful,  peevish,  and  unreasonable.  The  spirits 
are  often  depressed,  esi)ecially  in  the  earlier  months,  when  the  general 
nutrition  is  most  impaired.  The  melancholia  in  women  already  pre- 
disposed to  insanity  may  terminate  in  mania.  The  memory  is  gen- 
erally weakened,  especially  in  women  who  have  borne  a  number  of 
children  in  rapid  succession.  On  the  other  hand,  nervous  women 
sometimes  lose  their  nervousness,  and,  exceptionally,  there  are  individ- 
uals who  ex])erience  during  pregnancy  a  peculiar  sense  of  well-being. 
Neuralgic  affections  are  common  (face-ache,  toothache,  etc.) ;  local 
anaesthesia  and  paresis  occur  at  times;  the  senses  are  often  disordered 
(nyctalopia,  amaurosis,  amblyopia,  deafness,  perversions  of  taste  and 
smell)  ;  pruritus  is  sometimes  troublesome ;  and,  finally,  pregnant 
women  are  subject  to  attacks  of  dizziness  and  syncope. 


CHAPTER   V. 

THE  DIAGNOSIS  OF  PREGNANCY. 

Signs  of  pregnancy.— Suppression  of  menses. — Nausea. — Salivation.— Breasts. — In- 
crease of  abdomen.— Changes  of  the  os  and  cervix.— Quickening.— Ballotte- 
ment.— Fetal  heart-beat.— Uterine  bruit.— Funic  souffle.— Interrogation  of  the 
patient.— Methods  of  physical  e.xamination.— Inspection  of  abdomen.— Palpa- 
tion.—Auscultation.— The  vaginal  touch.— Distinction  between  first  and  sub- 
sequent pregnancies.— Diagnosis  of  death  of  foetus.— Duration  of  pregnancy.— 
Prediction  of  day  of  confinement  from  date  of  last  menstruation.— Date  of 
quickening. — Size  of  uterus. 

A  THOROUGH  familiarity  with  all  the  signs  which  lead  us  to  the 
recognition  of  pregnancy  is  an  essential  part  of  the   outfit   of  every 

*  Kaltenbach,  Ueber  Albuminurie  und  Erkrankungen  der  Harnorgane  in  der 
Fortpflanzungsperiode,  Arch.  f.  Gynaek.,  Bd.  iii,  p.  1. 


92 


PHYSIOLOGY   OF  PREGNANCY. 


practicing  physician.  The  reasons  for  this  are  obvious.  Mistakes  as 
to  the  diagnosis  of  the  pregnant  state  can  never  be  covered  up.  They 
therefore  inevitably  subject  the  author  of  them  to  criticism  and  ridi- 
cule. But,  apart  from  personal  considerations,  it  is  to  be  remembered 
that,  in  the  practice  of  both  medicine  and  surgery,  the  coexistence  of 
pregnancy  not  infrequently  modifies  materially  the  prognosis  and 
treatment.  Moreover,  it  is  one  of  the  most  grateful  functions  the 
physician  is  called  upon  to  perform  to  be  able  to  dissipate  unjust  sus- 
picions of  pregnancy,  which  sometimes  cloud  the  reputations  of  per- 
fectly pure  women.  On  the  other  hand,  the  writer  has  known  many 
cases  of  grievous  wrong  and  injustice  done  to  the  innocent  by  a  care- 
less, hasty,  and  incorrect  decision  on  the  part  of  the  medical  examiner. 
The  so-called  "  signs  of  pregnancy  "  are  based  upon  the  physiological 
changes  which  take  place  in  the  ovum,  and  the  changes  wrought  by 
the  growth  of  the  ovum  upon  the  maternal  organism.  Many  of  the 
signs,  therefore,  possess  little  weight,  and  serve  only  to  draw  attention 
to  the  possible  existence  of  pregnancy.  A  number  of  the  signs  taken 
together  furnish  cumulative  evidence  of  the  probability  of  pregnancy. 
There  are,  however,  single  signs,  which,  taken  individually,  make 
pregnancy  probable  ;  only  a  few  possess  a  positive  significance.  Hence 
the  rule  that  the  physician  keep  ever  in  mind  possible  sources  of  error, 
and,  in  cases  of  doubt,  that  he  maintain  a  prudent  reserve  in  the  ex- 
pression of  his  opinion. 

The  diagnosis  of  pregnancy  depends  upon  an  acquired  facility  in 
the  mental  grouping  of  symptoms  in  the  order  of  their  respective 
weight,  and  upon  a  familiarity  with  all  the  methods  by  which  objective 
symptoms  can  be  determined. 

We  have,  therefore,  to  consider : 

1.  The  signs  of  pregnancy,  with  their  limitations  and  possible 
sources  of  error. 

2.  Methods  of  physical  exploration. 

3.  The  differential  diagnosis  of  pregnancy. 

The  Signs  of  Pregnancy. 

The  suppression  of  the  menses  is,  to  most  women  who  have  been 
exposed  to  impregnation,  the  first  warning  of  the  occurrence  of  con- 
ception. Certainly,  where  they  have  been  previously  habitually  regu- 
lar, this  sign  rarely  leads  them  into  error.  Still,  it  is  by  no  means 
reliable.  To  estimate  it  at  its  true  value,  it  is  necessary  to  bear  in 
mind  the  numerous  aberrations  to  which  the  menstrual  function  is 
subject.  In  married  women  a  retardation  of  the  menses  for  a  few 
days,  or  even  two  or  three  weeks,  is  not  an  uncommon  occurrence. 
These  retardations  are  not  unusual  in  newly-married  women,  in  whom 
the  disturbance  appears  to  follow  the  novelty  of  the  matrimonial  rela- 


THE   DIAGNOSIS  OF   PREGNANCY. 


93 


tion.  Again,  they  may  be  the  result  of  colds,  fatigue,  and  mental 
emotions.  In  the  unmarried,  who,  by  reason  of  imprudent  conduct, 
have  had  occasion  to  fear  pregnancy,  a  retardation  sometimes  occurs 
as  the  result  of  pure  apprehension. 

The  causes  of  amenorrhoni  do  not  need  to  be  specified  here.  They 
are  operative  in  the  married  as  well  as  in  the  unmarried.  The  family 
physician,  howeyer,  cognizant  of  the  peculiarities  and  temperaments 
of  his  patients,  will  easily  recognize  such  conditions,  and  separate 
them  from  the  cessation  of  the  menses  induced  by  pregnancy.  Should 
any  doubt  exist,  of  course  it  would  be  proper  to  suspend  judgment, 
and  await  the  advent  of  other  symptoms  before  expressing  an  opinion. 

Pregnancy,  while  it  suspends  ovulation,  the  usual  concomitant  of 
menstruation,  is  not  incompatible  with  a  periodic  flow,  which  may 
obscure  the  diagnosis.  When  conception  occurs  immediately  j)rior  to 
a  menstrual  period,  it  frequently  does  not  arrest  the  discharge,  though 
it  usually  diminishes  the  amount.  A  few  women  have  periodic  dis- 
charges during  the  first  two  or  three  months  of  pregnancy,  and,  in 
very  rare  cases,  throughout  its  entire  duration.  Authors  have  like- 
wise recorded  instances  of  women  whose  habit  it  was  to  menstruate  (?) 
only  during  pregnancy  (Montgomery).  In  all  such  cases  it  is  probable 
that  the  haemorrhage  is  of  cervical  origin,  and  is  a  pathological  phe- 
nomenon. In  one  instance  my  friend  Dr.  L.  M.  Yale,  of  this  city, 
verified  the  presence  in  the  cervical  canal  of  a  small  mucous  polypus, 
with  the  removal  of  whicii  the  trouble  disappeared.  In  mentioning 
tlu'se  deviations  from  the  standard,  it  is  necessary  to  invite  the  student 
to  view  them  in  proper  perspective.  They  are  of  extremely  rare  oc- 
currence, and  the  physician  will  not  often  fall  into  error  who  main- 
tains a  skeptical  attitude  toward  cases  of  supposed  pregnancy  in  which 
apparently  normal  menstruation  is  reported  to  continue. 

In  women  who  are  Jiabitually  irregular,  or  in  Avhom  the  menstrual 
periods  are  absent  altogether,  the  question  of  the  existence  of  preg- 
nancy is  often  in  the  early  months  a  very  puzzling  one.  There  are 
now  and  then  patients  who  menstruate  only  at  long  intervals.  If  they 
once  suspect  pregnancy,  they  are  apt  to  simulate  other  corroborative 
signs  ;  or,  on  the  other  hand,  they  may  proceed  far  in  gestation  with- 
out the  slightest  misgivings  of  their  true  condition.  In  such  instances 
the  physician,  unless  he  bases  his  opinion  on  purely  objective  symp- 
toms, is  at  times  drawn  into  error,  which  places  both  himself  and  his 
patient  in  a  ludicrous  position. 

In  the  same  category  are  to  be  placed  cases  of  pregnancy  occurring 
in  nursing  women  before  the  return  of  the  menses,  in  young  girls 
before  the  appearance  of  menstruation,  and  in  women  who  have  aj)- 
parently  passed  the  climacteric. 

Among  the  sympathetic  disturbances,  those  of  the  stomach  possess 
the  greatest  diagnostic  importance.     Nausea  and  vomiting,  occurring 


94  PHYSIOLOGY   OF  PREGNANCY. 

especially  in  the  morning,  and  following  suppression. of  the  menses,  are 
signs  to  which  the  women  themselves,  and  the  laity  in  general,  attach 
great  value.  They  are,  however,  sometimes  absent  in  pregnancy,  while 
they  are  present  in  a  variety  of  other  conditions.  They  are  notable 
features  of  chlorosis,  where  they  are  likewise  often  associated  with  sus- 
pension of  menstruation.  However,  after  eliminating  other  morbid 
causes,  they  are  always  suspicious  symptoms  in  women  who,  in  their 
sexual  relations,  have  exposed  themselves  to  conception,  and  who  never 
experienced  similar  sensations  in  the  unimpregnated  state.  Abundant 
salivation  possesses  a  similar  significance.* 

Tingling  sensations  and  swelling  of  the  breasts,  turgescence  and 
pigmentation  of  the  areola,  the  development  of  the  glandular  follicles 
around  the  nipple,  enlargement  of  the  superficial  veins,  and  the  secre- 
tion of  milk,  are  valuable  though  not  infallible  signs  of  pregnancy. 
Thus,  painful  sensations  and  sympathetic  swelling  of  the  breasts  may 
depend  upon  pathological  conditions  of  the  sexual  organs.  To  be  of 
importance,  they  should  be  persistent  and  progressive.  The  coloration 
may  be  the  relic  of  a  previous  ])regnancy.  The  other  changes  in  the 
areola  rarely  lead  us  into  error  when  they  are  present,  but  I  have 
often  noted  their  entire  absence.  I  have  likewise  noted  cases  where 
there  was  entire  absence  of  milk  in  the  breasts  until  after  confinement. 
Numerous  and  very  curious  instances  of  milk  in  the  breasts  of  the 
non-pregnant  have  been  recorded.  The  importance  of  these  excep- 
tions is  greatly  lessened  by  the  fact  that  milk  rarely  appears  in  preg- 
nancy before  the  development  of  other  signs  which  enable  us  to  make 
the  diagnosis  certain. 

Iticrease  in  the  size  of  the  abdomen  during  the  child-bearing  period 
always  suggests  the  existence  of  pregnancy.  But  it  is  to  be  remem- 
bered that  it  is  not  invariably  of  uterine  origin.  Thus,  it  may  result 
from  ascites,  from  an  excessive  deposit  of  adipQse  tissue  in  the  abdom- 
inal walls,  from  tympanitic  distention,  and  from  various  abdominal 
tumors  having  no  connection  with  the  uterus.  If  the  enlargement 
proves  to  be  due  to  a  uterine  tumor,  we  have  then  to  exclude  fibroids 
in  the  earlier  months,  subinvolution,  and  the  increase  of  size  often 
associated  with  peri-uterine  inflammations.  The  absence  of  uterine 
enlargement  in  women  supposed  to  be  several  months  pregnant,  pos- 
sesses, of  course,  absolute  value  in  the  way  of  purely  negative  testi- 
mony. 

Hegar  regards  as  a  valuable  early  sign  of  pregnancy  the  softening 

*  A  pellicle,  formed  upon  the  surface  of  the  urine,  twenty-four  to  forty-eight 
hours  after  emission,  was  once  regarded  as  of  great  diagnostic  value.  It  received 
the  name  of  kiesteine,  and  has  been  found  to  consist  of  a  proteine  substance,  triple 
phosphates,  fungi,  and  infusoria.  It  is  not  invariably  present  in  the  urine  of 
pregnant  women.  It  may  occur  at  other  times,  and  has  even  been  found  in  the 
urine  of  the  male. 


THE   DIAGNOSIS  OP   PREGNANCY.  95 

and  compressibility  of  the  lower  uterine  segment  as  contrasted  with  the 
firm  tissues  of  the  cervix  and  the  fundus.  To  determine  its  existence 
the  thumb  should  be  introduced  into  the  vagina,  and  tlie  index-finger 
into  the  rectum  as  far  as  the  pocket  of  the  third  sphincter  ani.  The 
fundus  should  then  be  pushed  downward  by  pressure  exerted  through 
the  abdominal  walls,  when  the  fundus,  the  lower  uterine  segment,  and 
the  cervix  all  are  brought  within  the  reach  of  the  index-finger.  The 
sign,  however,  is  not  conclusive,  as  its  absence  has  been  observed  in 
early  pregnancy,  and  a  condition  closely  simulating  it  has  been  noticed 
in  certain  morbid  states  of  the  non-pregnant  uterus.* 

The  changes  in  the  os  and  cervix  uteri  are  of  great  value  in  decid- 
ing the  question  of  pregnajicy.  They  consist  of  softening  and  cedema- 
tous  swelling  of  the  cervix,  velvety  character  of  the  mucous  mem- 
brane, associated  with  increased  cervical  secretion.  In  primiparje  the 
external  orifice,  instead  of  offering  the  sensation  of  a  transverse  slit, 
feels  circular.  In  multipara?  the  tip  of  the  finger  penetrates  to  a 
greater  depth  than  in  its  former  state.  During  the  first  two  months 
the  changes  are  rarely  sufficiently  marked  to  distinguish  them  from 
conditions  that  obtain  at  or  near  the  menstrual  period. 

Quicketiimi  is  the  term  used  to  designate  the  earliest  movements  of 
the  foetus  perceived  by  the  mother.  They  are  at  first  slight,  and  have 
been  compared  "  to  the  tremulous  motion  of  a  little  bird  held  in  the 
hand  "  (Montgomery).  Modern  investigations  place  the  time  at  which 
the  foetus  first  begins  to  employ  its  muscles  at  about  the  tenth  week. 
It  is,  however,  somewhat  rare  for  these  movements  to  excite  the  at- 
tention of  the  mother  before  the  sixteenth  to  the  eighteenth  week, 
though  experienced  matrons  may  recognize  them  at  an  earlier  period. 
Ilyperaesthetic  women  do  so,  I  should  say,  as  a  rule.  The  clear  state- 
ments of  intelligent  women  leave  me  no  reason  to  doubt  that  they  may 
feel  life  as  early  as  the  twelfth  week.  At  first  the  sensation  is  that  of 
a  flutter  or  tap,  but  the  intensity  of  the  movements  is  increased  as 
pregnancy  advances.  They  are  rendered  more  active  by  a  long  fast, 
and  by  certain  positions  in  bed.  For  considerable  periods  during  the 
day  they  disappear  altogether.  Occasionally  they  may  be  suspended 
for  days  or  Aveeks  at  a  time,  without  the  life  of  the  child  having  become 
necessarily  compromised.  Cases  have  been  cited  in  wdiich  women  have 
never  recognized  the  feeling  of  quickening  throughout  the  entire 
period  of  pregnancy.  Dropsy  of  the  amnion  and  ascites  are  said  to 
obscure  the  sensation  of  the  fetal  movements. 

The  subjective  impressions  of  women  as  to  quickening  require, 
however,  to  be  received  with  reserve.  Instances  are  not  infrequent 
where  sterile  women,  misled  by  their  eager  longings  for  maternity, 
have  not  only  deceived  themselves,  but  have  succeeded  in  betraying 

*  Vide  Compes,  Berliner  klinischer  Wochenschrift,  No.  38,  1885, 


96 


PHYSIOLOGY   OF   PREGNANCY. 


their  medical  advisers  into  error  by  their  confident  assurances  of  hav- 
ing distinctly  felt  the  movements  of  the  child  in  the  womb. 

Fetal  movements,  on  the  other  hand,  when  recognized  by  the 
medical  expert,  furnish  conclusive  evidence  of  pregnancy.  These 
movements  may  be  active  or  passive.  Active  movements  may  be  de- 
tected by  the  eye,  or  by  immediate  contact.  They  seldom  assume 
much  distinctness  before  the  sixth  month,  though  this  is  not  invari- 
ably the  rule.  (Thus,  a  patient  of  mine,  the  mother  of  six  children, 
aborted  at  the  fourth  month.  The  ovum  was  expelled  on  the  27th 
of  March.  She  gave  birth  on  the  35th  of  December  following— i.  e., 
just  nine  months  later— to  a  full-term  child.  In  the  latter  part  of 
July  the  movements  were  clearly  appreciable  to  both  the  sight  and 
touch.)  At  first  the  sensation  is  that  of  a  simple  pat  or  throb,  but  in 
the  sixth  and  seventh  months  tiie  limbs  may  be  felt  to  escape  from 
under  the  hand  with  a  rolling  or  gliding  movement.  In  the  last  two 
months,  in  women  with  lax  abdominal  parietes,  it  is  sometimes  pos- 
sible to  seize  with  the  fingers  a  limb  of  the  foetus,  especially  when  it 
chances  to  form  a  projection  recognizable  through  the  intermediate 
coverings.  The  fetal  movements  have  been  closely  simulated  by  the 
irregular  and  spasmodic  action  of  certain  of  the  abdominal  muscles. 
In  the  celebrated  case  of  Joanna  Southcote,  who  at  the  age  of  sixty- 
four  claimed  to  be  with  child  by  the  Holy  Ghost,  Dr.  Eeece  says,  "  I 
felt  something  move  under  my  hand,  possessing  a  kiiul  of  undulatory 
motion,  and  appearing  and  disappearing  in  the  same  manner  as  a 
foetus."* 

Ballottement  is  the  term  applied  to  the  passive  movements  commu- 
nicated to  the  foetus  by  the  physician.  It  may  be  performed  either  by 
impressing  the  uterine  contents  with  the  two  hands  laid  upon  the 
abdominal  wall,  so  as  to  cau.se  tiie  intervening  body  to  float  between 
them  ;  or  by  introducing  two  fingers  into  the  vagina  and  pushing  them 
suddenly  against  the  lower  segment  of  the  uterus  just  anterior  to  the 
cervix.  When  this  is  done,  the  head,  if  the  presenting  part,  is  made 
to  bound  away  from  the  fingers,  to  drop  down  again  in  a  few  moments 
upon  them  with  a  gentle  tap.  Vaginal  ballottement  can  sometimes 
be  practiced  successfully  as  early  as  the  latter  part  of  the  fourth  month. 
Ballottement  is  to  be  regarded  as  positive  proof  of  pregnancy,  as  there 
is  no  other  condition  in  which  a  solid  body  is  found  floating  in  the 
uterine  cavity. 

The  important  auscidtatory  signs  consist  of  the  uterine  bruit  and 
the  sounds  of  the  fetal  heart.  The  discovery  of  the  latter  was  made 
by  M.  Mayor,  a  surgeon  of  Geneva,  as  appears  by  the  following  note 
contributed  by  the  editor  of  the  Bibliotheque  Universelle,  in  speak- 
ing of  the  co7npte  rendu  made  by  Percy,  June  29, 1818,  to  the  Academy 
of  Sciences,  upon  the  memoir  of  Laennec  relative  to  auscultation; 
*  Montgomery,  Signs  of  Pregnancy,  second  edition,  p.  144. 


THE  DIAtJNOSIS  OP   PREGNANCY.  9^ 

"  This  observation  reminds  us  of  one  made  by  M.  Mayor,  which  has 
appeared  very  interesting  to  us  in  its  connection  with  the  art  of  mid- 
wifery and  legal  medicine.  He  has  discovered  that  it  is  possible  to 
recognize  with  certainty  whether  a  child  is  living  or  no,  by  applying 
the  ear  to  the  abdomen  of  the  mother  of  the  child  ;  if  the  child  is  liv- 
ing, one  can  hear  very  well  the  beatings  of  its  heart,  and  distinguish 
them  from  those  of  the  maternal  pulse."  *  Time  has  served  only  to  con- 
firm in  the  most  complete  manner  the  accuracy  of  this  statement.  The 
heart-sounds  of  the  foetus,  when  once  clearly  heard,  are  now  regarded 
as  the  most  valuable  of  the  signs  of  pregnancy,  and  conclusive  evidence 
that  the  child  is  alive.  They  are,  like  those  of  the  mother,  distinctly 
double,  and  have  been  aptly  compared  by  Kergaradec  to  the  tick-tack  of 
a  watch.  They  are  much  more  rapid  than  the  corresponding  sounds, 
in  the  heart  of  the  mother,  oscillating  between  120  and  160  per  minute. 
They  may  be  temporarily  increased  in  frequency  by  movements  of  the 
mother,  and  by  both  the  active  and  passive  movements  of  the  child. 
At  the  beginning  of  a  pain,  especially  after  rupture  of  the  membrane, 
the  heart-sounds  often  become  more  frequent ;  on  the  other  hand,  they 
become  slowed  during  the  height  of  the  contraction,  and  may  even  for 
the  moment  cease  altogether,  either  in  consequence  of  the  compression 
of  the  child's  body,  or  as  the  result  of  the  disturbance  produced  in  the 
placental  circulation.  In  the  interval  between  the  pains,  the  average 
frequency  is  usually  restored.  If  at  any  time  the  frequency  of  the 
heart-beat  permanently  either  rises  above  or  falls  below  the  normal 
average,  the  child's  life  is  to  be  regarded  as  endangered.  As  the  fetal 
circulation  is  entirely  independent  of  that  of  the  mother,  there  is  no 
direct  relation  between  the  rapidity  of  the  pulsations  of  the  fetal  and 
maternal  hearts.  However,  in  the  febrile  affections  of  the  mother, 
the  health  of  the  child  may  become  coincidently  deranged,  with  re- 
sulting increase  in  the  frequency  of  its  heart's  sounds.  In  general,  the 
heart  beats  more  frequently  in  girls  than  in  boys — a  circumstance  prob- 
ably owing  to  the  average  smaller  size  of  the  female  at  birth.  In 
fifty  observations,  Frankenhaeuser  f  found  the  average  in  the  boys  was 
124,  while  that  of  the  girls  was  144.  He  believed,  therefore,  that  it 
would  prove  possible  to  predict  the  sex  of  the  child  m  utero  three 
months  previous  to  confinement.  Subsequent  experience  has  demon- 
strated, however,  that  prophecies  based  upon  the  frequency  of  the 
heart-beats  are  at  best  of  only  approximative  value,  and  that  it  is 
the  part  of  wisdom  to  reserve  a  prognosis  which  may  be  falsified  by 
time. 

The  fetal  heart  may  generally  be  made  out  by  the  eighteenth  to 
the  twentieth  week.  Under  favorable  circumstances  it  has  been  de- 
tected as  early  as  the  fifteenth  to  the  sixteenth  week.     It  is  usually 

*  .JouLiN,  Traite  complet  d'accouchement,  1867,  p.  410. 
f  Monatsschr.  f.  Geburtsk.,  Bd.  xiv,  p.  161. 
7 


98  PHYSIOLOGY  OF   PREGNANCY. 

heard  over  the  dorsum  of  the  fa?tus ;  in  face-presentations,  on  the 
contrary,  it  is  heard  most  distinctly  over  the  anterior  surface  of  the 
thorax.  The  sound  is  often  obscured  by  the  thickness  of  the  abdomi- 
nal walls  in  fat  women,  and  by  an  excessive  amount  of  amniotic  fluid. 
When  the  dorsum  of  the  fcetus  is  turned  posteriorly,  it  may  be  absent 
altogether.  It  is  customary,  therefore,  to  make  frequent  examinations 
at  intervals  before  deciding,  in  consequence  of  its  failure,  upon  the 
death  of  the  child. 

The  lUerine  bruit  is  a  blowing  sound  synchronous  with  the  mater- 
nal pulse.  It  resembles  strongly  the  souffle  heard  in  aneurismal 
tumors,  and  varies  greatly  in  quality  and  intensity.  It  is  apt  to  be 
louder  in  markedly  anemic  women.  During  the  uterine  contractiojis 
it  possesses  more  of  a  musical  character ;  at  the  height  of  a  pain  it  may 
disappear  for  the  moment.  It  may  be  modified  by  the  pressure  of 
the  stethoscope  or  arrested  altogether.  When  first  discovered  by 
Kergaradec  (1822),  it  was  attributed  to  the  utero-placental  circula- 
tion, and  was  therefore  termed  the  placental  bruit.  As,  however,  it 
was  found  to  persist  two  or  three  days  after  delivery,  it  became  evident 
that  the  sound  must  be  of  uterine  origin.  It  is  now  the  generally 
accepted  belief  that  the  sound  is  produced  in  the  ascending  branches 
of  the  arteria  uterina.  Rotter*  and  Rapin  have  shown  that,  in  press- 
ure along  the  course  of  the  artery,  both  when  made  through  the  ab- 
dominal walls  and  through  the  vagina,  a  vibratory  thrill  may  be  ex- 
perienced by  the  touch,  which  corresponds  to  the  sounds  heard  in 
auscultation. 

It  is  seldom  heard  before  the  fourth  month.  Spiegelberg  f  states 
that,  in  women  with  lax  abdominal  ])arietes,  he  has  succeeded,  by 
pressing  the  stethoscope,  placed  above  the  symphysis  jiubis,  deep  down- 
ward so  as  to  reach  the  sides  of  the  lower  portion  of  the  uterus,  in 
detecting  the  murmur  as  early  as  the  eighth  to  the  ninth  week.  As  a 
sound  similar  to  the  uterine  bruit  may  sometimes  be  detected  in  uter- 
ine fibroids,  its  value  as  a  distinctive  sign  of  pregnancy  is  thereby 
greatly  impaired. 

A  hissing  sound  synchronous  with  those  of  the  fetal  heart  is  some- 
times heard  in  auscultating  the  abdomen.  This  sound  is  referable  to 
the  umbilical  cord,  and  is  termed  the  funic  souffle.  Its  etiology  is  a 
matter  of  conjecture.  As  it  is  only  found  in  fourteen  to  fifteen  per 
cent  of  cases  examined,  it  possesses  moderate  value  as  a  sign  of  preg- 
nancy. 

It  is  sometimes  possible  to  detect  the  sound  of  the  fetal  move- 
ments as  early  as  the  fourteenth  to  the  sixteenth  week,  i.  e.,  a  month 
earlier  than  the  sounds  of  the  fetal  heart.  It  possesses  a  rubbing, 
crepitant  character,  resembling,  according  to  Schulze,  the  sound  pro- 

*  Rotter,  Ueber  fiihlbares  Uteringerausch,  Arch.  f.  Gynaek.,  p.  539. 
f  Lehrbuch  der  Geb.,  p.  104. 


THE  DIAGNOSIS  OF  PREGNANCY.  99 

duced  when  the  thumb  is  placed  over  the  ear  aud  the  nail  is  scraped 
by  the  nail  of  another  finger.* 

Interrogation  of  the  Patient.— In  all  cases  of  presumed  pregnancy 
it  is  customary  to  commence  an  investigation  by  preliminary  inquiries 
as  to  the  existence  of  tiie  more  important  subjective  symptoms.  As 
such  are  to  be  regarded  the  suppression  of  the  menses,, the  so-called 
"  morning-sickness,"  salivation,  pricking  sensations  and  lancinating 
pains  in  the  breasts,  enlargement  of  the  abdomen,  and  quickening. 
As  we  have  already  seen,  however,  none  of  these  symptoms  are  really 
decisive.  Patients,  by  their  statements,  may  in  perfect  good  faith  lead 
the  physician  into  error ;  or,  where  they  have  an  interest  in  practicing 
deception,  may  deny  the  existence  of  incriminating  symptoms  alto- 
gether. It  is,  therefore,  often  necessary  to  supplement  the  testimony 
of  patients  by  the  evidences  to  be  obtained  by  a  clinical  examination. 
Ordinarily  the  vaginal  touch  suffices.  In  a  few  cases  of  doubt  it  may 
be  necessary  to  possess  one's  self  of  all  the  objective  signs  before  arriv- 
ing at  a  conclusion. 

Methods  of   Physical  Exploration. 

The  patient  may  be  examined  in  the  upright  or  in  the  recumbent 
position.  In  the  upright  position,  the  physician  may  first  examine  the 
breasts,  with  reference  to  the  existe^jce  of  the  changes  characteristic 
of  pregnancy.  With  the  eye  he  takes  note  of  the  oedema  and  discolor- 
ation of  the  areola,  the  development  of  the  follicles^  the  secondary 
areola,  aud  the  increased  size  of  the  organ.  To  distinguish  from  the 
enlargement  of  the  breast  due  to  adipose  tissue,  he  looks  for  the 
presence  of  developed  veins  upon  its  surface,  and  with  the  touch 
recognizes  the  knotty,  uneven  feel  produced  by  the  development 
of  the  glandular  tissue.  By  pressing  the  breast  near  the  nipple 
between  the  thumb  and  index-finger  the  presence  of  milk  may  be 
determined. 

An  examination  j)er  cwjinam  is  sometimes  made  in  the  upright 
position,  in  cases  where  the  physician  desires  simply  to  rapidly  ac- 
quaint himself  with  the  condition  of  the  generative  passages  and  the 
lower  portion  of  the  uterus.  The  patient  either  stands  with  the  feet 
apart,  or  with  one  foot  raised  upon  a  stool,  while  the  physician,  kneel- 
ing before  her,  encircles  her  hips  with  the  left  arm,  and  with  the  right 
hand  passed  beneath  the  clothing  makes  the  requisite  exploration.  ^ 
This  method  furnishes  incomplete  results,  and  is  apt  to  offend  sensi- 
tive patients.  It  possesses  no  advantages  over  that  in  the  recumbent 
position,  and  is  rarely  resorted  to  except  in  the  hurry  of  office  practice. 

Although  for  certain  purposes  it  may  prove  advantageous  to  choose 
the  lateral  or  knee-chest  position,  in  all  ordinary  cases  it  is  advisable 

*  J.  Veit,  Mtiller's  Handbueh,  vol.  i,  p.  311. 


■^QQ  PHYSIOLOGY   OP  PREGNANCY. 

to  examine  the  patient  upon  her  back,  as  being  most  convenient  for 
both  external,  internal,  and  conjoined  exploration. 

In  the  dorsal  position  the  body  should  be  as  nearly  horizontal  as 
possible,  with  the  head  and  shoulders  resting  upon  a  pillow,  and  the 
thighs  flexed  at  right  angles  to  the  body  and  separated  from  one 
another.  In  this  way  the  greatest  possible  relaxation  of  the  abdominal 
walls  and  of  the  perinaeum  is  attained.  Corsets,  or  other  articles  of 
apparel  interfering  with  freedom  of  investigation,  should  be  removed. 
The  woman  should  be  covered  with  a  sheet,  and  the  clothes  reflected 
upward  so  as  to  expose  the  abdomen.  Where  actual  inspection  is  not 
necessary,  it  is  well  to  draw  the  chemise  smoothly  over  the  abdominal 
walls,  to  avoid  offending  the  modesty  of  the  patient.  When  it  is  of  im- 
portance to  survey  the  external  surface,  care  should  be  taken  to  so 
arrange  the  sheet  as  to  cover  the  pubic  region. 

Inspection  of  the  abdomen  enables  us  to  recognize  its  form  and 
shape,  the  coloration  of  its  surface,  the  striae  due  to  distention,  and 
the  condition  of  the  navel.  A  flattening  of  the  abdomen  at  the  um- 
bilical region,  with  bulging  at  the  sides,  would  lead  to  the  suspicion  of 
ascites.  A  depression  of  the  navel  is  incompatible  with  advanced 
pregnancy.  Fetal  movements  are  sometimes  visible  through  the  ab- 
dominal prarietes. 

Palpation  of  the  abdomen  enables  us — 1,  to  recognize  the  size, 
shape,  and  consistency  of  the  uteYine  tumor,  and  to  distinguish  it  from 
other  intra-abdominal  growths ;  2,  to  ascertain,  in  advanced  preg- 
nancy, the  presence  of  the  fwtus.  In  a  very  large  number  of  cases 
palpation  alone  serves  to  establish  the  existence  of  pregnancy.  It  is, 
however,  only  after  the  third  month  of  pregnancy,  when  the  fundus 
uteri  can  be  felt  above  the  symphysis  pubis,  that  this  method  of  ex- 
ploration becomes  available. 

In  its  performance  the  physician  stands  by  the  side  of  the  patient, 
and  with  the  tips  of  his  fingers  rapidly  traverses  the  abdomen  from  the 
pubes  upward.  In  this  way  he  takes  note  of  the  thickness  of  the  ab- 
dominal walls  and  of  the  general  position  of  the  uterus.  The  latter 
may  then  be  outlined  by  pressing  the  abdominal  walls  inward  to  the 
sides  of  the  uterus,  with  the  ulnar  borders  of  the  two  hands.  The 
uterus  is  then  steadied  with  one  hand,  while,  with  the  other,  intermit- 
tent pressure  is  made  to  determine  the  consistence  of  the  tumor.  In 
pregnancy,  after  the  second  month,  the  uterus  becomes  soft  and  elas- 
tic, a  condition  that  increases  with  the  growth  of  the  ovum,  so  that, 
toward  the  end,  palpation  often  furnishes  an  obscure  sense  of  fluctu- 
ation. The  physician  should  next  turn  his  face  toward  the  feet  of  his 
patient,  and  make  deep  pressure  above  the  symphysis  pubis  to  the 
lower  borders  of  the  uterus.  He  should  here  seek  to  discover  the  vi- 
bratory thrill,  which  may  sometimes  be  detected  along  the  course  of 
the  uterine  arteries.     At  the  same  time,  in  head-presentations  (after 


THE  DIAGNOSIS  OF   PREGNANCY.  1q1 

the  sixth  month),  a  hard,  round  body  can  generally  be  felt,  and  made 
to  float  to  and  fro  between  the  examining  fingers  of  the  two  hands. 
In  thin  persons,  with  relaxed  abdominal  and  uterine  parietes,  it  is  pos- 
sible, in  the  later  months,  to  trace  upward  the  Vjack,  the  breech,  and 
the  extremities  of  the  foetus.  The  dorsal  surface  may  be  rendered 
more  distinct  by  pressure  on  the  breech,  so  as  to  augment  the  dorsal 
curve  (Budin).  During  the  progress  of  the  examination  in  advanced 
pregnancy,  the  movements  of  tlie  child  are  usually  excited,  and  are 
readily  appreciated. 

The  Differential  Diagnosis  of  Pregnancy. 

The  differential  diagnosis  between  pregnancy  and  other  sources  of 
abdominal  enlargement  is  in  most  cases  not  difficult.  In  subperitoneal 
myomata  of  the  uterus,  the  unevenness  of  the  surface  and  the  hardness 
of  the  tissues  are  distinctive.  But  it  must  be  remembered  that 
myomata,  though  they  commonly  cause  sterility,  do  not  actually  ex- 
clude pregnancy.  In  the  rare  cases  in  which  myomata  and  pregnancy 
coexist,  the  diagnosis  for  a  time  may  be  doubtful. 

Braxton  Hicks*  lays  great  stress  on  the  fact  that,  from  the  third 
month  to  the  completion  of  labor,  spontaneous  contractions  of  the 
uterus  take  place,  lasting  generally  from  one  to  two  minutes,  and  oc- 
curring at  intervals  of  from  five  to  twenty  minutes.  This  enables  us  to 
determine  the  fact  of  pregnancy,  and  that  the  pregnancy  is  intra- 
uterine. It  occurs  likewise  in  degenerations  of  the  ovum,  and  in 
cases  of  a  dead  foetus.  He  found,  too,  that  where  pregnancy  coexisted 
with  myomata  the  exact  relations  of  the  uterus  were  readily  made  out 
by  the  alteration  which  occurred  at  short  intervals  in  the  density  of 
the  uterus. 

It  is  therefore  important,  where  any  uncertainty  exists,  to  abstain 
from  the  use  of  sounds  and  to  await  the  result  of  a  future  examination. 
In  a  few  weeks'  time  the  rapid  growth  of  the  pregnant  uterus,  quick- 
ening, ballottement,  and  the  fetal  heart  will  furnish  the  necessary  data 
for  establishing  the  distinction. 

Ovarian  cysts,  in  the  early  stages  of  their  growth,  occupy  a  position 
to  the  side  of  the  pelvis,  and  are  hardly  likely  to  be  confounded  with 
the  pregnant  uterus.  When,  however,  by  their  increase  in  size,  they  fill 
the  abdomen,  the  history  of  ovariotomy  shows  that,  without  a  full  and 
complete  examination,  such  a  mistake  is  possible.  Where  ovarian 
cysts  are  complicated  by  pregnancy,  the  latter  has  been  at  times  over- 
looked, simply  because  it  was  not  so  much  as  suspected.  Thus,  a 
young  servant-girl  was  sent  to  me  some  years  ago  to  consult  me  rela- 
tive to  the  nature  of  an  abdominal  tumor.  The  diagnosis  of  ovarian 
cyst  was  readily  established.  A  year  later  she  sought  the  advice  of  a 
*  Trans.  Internat.  Med.  Congress,  1887. 


-^Q2  PHYSIOLOGY   OF   PREGNANCY. 

surgeon,  formerly  of  this  city,  who  counseled  its  removal.  Having  ob- 
tained her  consent,  he  made  the  usual  incision  in  the  median  line,  and 
exposed,  to  his  horror,  the  pregnant  uterus.  He  afterward  learned 
that  the  girl,  having  been  assured  that  conception  was  impossible  on 
account  of  the  ovarian  disease,  had  yielded  to  the  solicitations  of  her 
lover.  Finding  herself  pregnant,  she  purposely  concealed  her  con- 
dition, and  had  sought  the  operation  when  seven  months  advanced,  in 
the  hope  that  a  fatal  issue  would  cover  her  shame.  The  ovarian  tumor 
was  left  untouched,  and  the  wound  was  quickly  closed.  The  girl 
died,  however,  a  few  days  afterward.  In  this  case,  the  undoubted 
presence  of  an  ovarian  cyst  and  the  reputable  character  of  the  girl 
combined  to  disarm  suspicion. 

In  ovarian  cysts  there  is,  on  palpation,  ordinarily  greater  distinct- 
ness of  fluctuation  than  in  the  gravid  uterus.  Tlie  diagnosis  is,  how- 
ever, mainly  based  upon  the  presence  or  absence  of  the  usual  signs  of 
pregnancy. 

Thick  layers  of  fat  in  the  abdominal  walls  and  ascites  could  hardly 
be  mistaken  for  pregnancy,  though  they  may  serve  to  obscure  palpation. 

Tympanitic  distention  is  recognized  in  part  by  the  character  of 
the  percussion  note,  and  in  part  by  demonstrating  the  absence  of  the 
uterine  tumor.  The  latter  is  accomplished  by  directing  the  patient  to 
make  alternate  deep  inspirations  and  prolonged  expirations.  The  phy- 
sician then  places  the  left  hand  upon  the  abdomen.  During  the  long 
inspiration  he  remains  passive;  with  the  expiration,  he  presses  with 
the  fingers  of  the  right  hand,  placed  obliquely  against  those  of  the 
left,  in  the  direction  of  the  spinal  column.  With  the  recurrence  of 
inspiration,  he  holds  steadily  the  ground  previously  gained.  During 
the  following  expiration  further  progress  is  made,  and  thus  ])y  succes- 
sive advances,  in  case  no  intervening  body  prevents,  the  hand  is  made 
to  sink  inward  until  the  vertebra?  are  felt.*  In  cases  of  undue  sensi- 
tiveness of  the  abdominal  walls,  chloroform  may  be  administered  to 
complete  anaesthesia.  Some  patients,  by  means  of  contractions  of  the 
abdominal  muscles,  succeed  in  producing  the  semblance  of  a  tumor, 
which  may  even  be  mapped  out  with  the  hands  applied  to  the  ab- 
domen. These  so-called  "  phantom  tumors "  occur  most  commonly 
in  liysterical  women  who  are  earnestly  desirous  of  becoming  mothers. 
They  are  eminently  calculated  to  entrap  the  unwary,  if  the  examina- 
tion be  confined  to  the  abdomen  or  to  listening  to  the  patient's  sub- 
jective symptoms.  They  flatten  down  and  disappear  under  chloro- 
form, or  when  the  attention  is  distracted  during  the  course  of  an  in- 
vestigation. 

Auscultation  furnishes  the  most  certain  evidences  of  the  existence 
of  pregnancy.     The  stethoscope  may  be  employed,  or  the  ear  may  be 

*  This  valuable  method  is  borrowed  from  Professor  Spiegelberg's  Diagnose  der 
Eierstocktumoren,  Volkmann's  Samral.  klin.  Vortr.,  No.  55. 


THE   DIAGNOSIS   OF   PREGNANCY.  iq^ 

applied  directly  to  the  abdomen.  To  hear  the  fetal  heart  requires  a 
certain  amount  of  practice,  but  the  art  can  be  readily  acquired.  As 
the  sounds  are,  at  best,  of  feeble  intensity,  the  utmost  stillness  in  the 
neighborhood  of  the  patient  is  necessary  for  this  appreciation.  Thev 
are  always  heard  with  great  difficulty  before  the  end  of  the  sixth 
mouth.  There  is  no  special  point  at  which  they  can  be  invariably  dis- 
tinguished. In  head  or  breech  presentations,  with  the  back  of  the 
iaitns  curved  and  in  contact  with  the  uterine  wall,  the  sounds  are  most 
clearly  to  be  made  out  over  its  dorsal  aspect.  In  face-presentations, 
on  the  contrary,  the  anterior  surface  of  the  child  is  pressed  against  the 
uterine  walls,  and  the  sounds  are  heard  with  the  greatest  distinctness 
over  the  chest.  As  in  the  last  three  months  of  pregnancy  the  cephalic 
presentations,  with  the  back  to  the  left,  preponderate,  the  heart-sounds 
are  oftenest  heard  in  a  line  extending  from  the  anterior  superior  spi- 
nous process  to  the  umbilicus.  When  the  back  of  the  child  is  turned 
to  the  right,  they  are  likewise  directed  somewhat  posteriorly.  The 
heart-sounds  are  then  less  accessible,  and  therefore  appear  feebler. 
Care  must  be  taken  not  to  confound  with  the  fetal  heart  the  con- 
ducted heart-sounds  of  the  mother,  or  the  aortic  pulse.  Thick  ab- 
dominal walls,  or  abundant  amniotic  fluid,  may  interfere  with  the 
recognition  of  the  heart-sounds.  When  the  back  of  the  child  is  turned 
to  the  rear,  or  during  a  uterine  contraction,  they  may  disappear  alto- 
gether. If  the  child  be  living,  however,  repeated  examinations  will  not 
fail  to  detect  them.  The  uterine  souffle  is  heard  with  maximum  in- 
tensity to  the  sides  of  the  uterus.  In  the  early  months  it  is  to  be 
sought  for  near  the  median  line,  just  over  the  symphysis  pubis. 

T/ie  vaginal  touch  enables  one  to  effect  an  examination  of  the 
genital  canal  and  that  portion  of  the  uterus  which  is  contained  within 
the  pelvic  cavit3^  The  accoucheur  should  accustom  himself  to  use 
either  hand  Avith  equal  ease,  and  to  conduct  an  examination  upon 
whichever  side  of  the  bed  his  patient  chances  to  be  lying.  The  index- 
finger  should  be  anointed  with  cold  cream,  lard,  butter,  vaseline,  oil, 
or  simple  soap  and  water,  to  make  its  introduction  into  the  vagina  less 
painful.  As  the  hand  is  passed  under  the  clothes,  it  is  a  good  plan 
to  cover  the  index  with  the  thumb  and  remaining  fingers,  to  prevent 
its  soiling  the  patient's  wearing-apparel.  The  patient  should  now  be 
told  to  separate  her  knees  widely,  while  the  index-finger  glides  for- 
ward over  the  perinaeum  to  the  introitus  vagina.  Note  should  be 
taken  here  of  the  size  and  direction  of  the  orifice,  and  the  degree  of 
resistance  offered  by  the  external  parts.  Where  there  is  much  hair 
about  the  pubes,  the  introduction  of  the  index-finger  into  the  vagina 
is  greatly  favored  by  separating  the  labia  with  the  fingers  of  the  other 
hand.  As  the  finger  enters  the  vagina,  it  is  well  to  notice  the  urethra, 
the  condition  of  the  rectum  (whether  filled  with  fiBces),  the  length  and 
width  of  the  vagina,  and  the  amount  of  lubricating  secretion  furnished 


JQ4  PHYSIOLOGY   OF  PREGNANCY. 

by  the  vaginal  walls.  To  explore  the  anterior  half  of  the  pelvis,  close 
the  unemployed  fingers  upon  the  palm  of  the  hand,  direct  the  palmar 
surface  of  the  index-finger  to  the  front,  and  press  upward  to  the  pre- 
senting part.  In  the  early  months,  place  the  unemployed  hand  upon  the 
abdomen  above  the  symphysis  pubis,  and,  by  conjoined  manipulation, 
make  out  the  size,  shape,  and  consistence  of  the  uterus.  If  pregnancy 
is  sufficiently  advanced,  ballottement  may  be  produced.  To  reach  the 
cervix,  the  finger  should  be  next  turned  to  the  rear.  Many  practi- 
tioners prefer  to  extond  the  previously  closed  fingers,  and  press  them 
opened  against  the  perineum.  Should  the  cervi x  not  be  readily  reached, 
the  examination  should  be  made  with  both  the  index  and  middle 
fingers.  If  the  middle  finger  is  introduced  slowly  and  with  care,  it 
gives  no  additional  jiain,  and  increases  the  reach  by  nearly  an  inch. 
The  actual  distance  to  the  cervix  may  be  diminished  by  placing  the 
closed  hand  under  the  extremity  of  the  sacrum,  so  as  to  diminish  the 
degree  of  pelvic  inclination.  It  is  often  necessary  to  resort  to  this  meas- 
ure when,  toward  the  end  of  pregnancy,  the  cervix  is  situated  un- 
usually high  up  and  is  directed  well  to  the  rear.  AVith  the  touch,  we 
recognize  the  size  and  thickness  of  the  cervix,  the  length  of  both  the 
anterior  and  posterior  walls,  the  shape  of  the  os,  and,  if  open,  the 
character  of  the  cervical  canal. 

The  rectal  touch  is  only  necessary  where  there  is  oV)literation  of  the 
vagina — a  condition  which  does  not  exclude  ])regnancy,  but  it  is  some- 
times usefully  resorted  to  in  other  cases  to  complete  information  ob- 
tained by  vaginal  exploration. 

The  bluish  coloration  of  the  vulvar  and  vaginal  mucous  membrane 
is  of  considerable  diagnostic  importance.  Chadwick  *  has  recently 
drawn  attention  to  tlie  value  of  simple  inspection  of  the  vaginal  orifice, 
without  employment  of  the  speculum.  A  faint  diffused  bluish  tint  he 
regards  as  suggestive ;  a  faint  bluish  tint  limited  to  the  anterior 
vaginal  wall  he  regards  as  characteristic  and  diagnostic ;  wliile  a  deep 
blue  tint  is  a  nearly  absolute  proof  of  pregnancy.  The  sign  is  often 
available  as  early  as  tlie  end  of  the  second  month.  Chadwick's  tables 
show  that  in  the  second  half  of  pregnancy  the  color  is  of  such  a 
character  as  to  be  in  the  rule  diagnostic.  My  own  experience  is  en- 
tirely in  accord  with  that  of  Dr.  Chadwick.  In  many  instances  where 
pregnancy  had  been  concealed  or  not  suspected,  this  sign  has  served 
me  as  a  warning  against  the  performance  of  an  operation  contra-in- 
dicated by  the  pregnant  state. 

Distinction  between  First  and  Subsequent  Pregnancies. 

In  women  who  have  once  completed  the  full  term  of  utero-gesta- 
tion,  the  imprints  left  by  the  pregnant  state  are  indelible  and  easy  to 

*  Chadwick,  Vaginal  Coloration  in  Pregnancy,  Trans.  Am.  Gyn.  Soc,  p.  399. 


THE  DIAGNOSIS  OF  PREGNANCY.  *  ^qS 

recognize.  As  it  is  sometimes  a  matter  of  forensic  importance  for  a 
physician  to  be  able  to  distinguish  between  first  and  subsequent  preg- 
nancies, it  is  desirable  for  every  practitioner  to  make  himself  familiar 
with  the  characteristic  differences  between  the  two  conditions. 

In  priinipane  the  abdominal  integuments  are  firm  and  tense,  so 
that  it  is  difficult  to  map  out  through  them  the  underlying  uterus, 
or  to  feel  the  head,  the  breech,  or  the  limbs  of  the  child.  The  stri« 
found  upon  the  abdomen,  the  nates,  and  the  thighs  appear  late  in 
pregnancy,  and  have  a  reddish-brown  or  slaty  color.  The  breasts  are 
full,  firm,  and  sensitive  to  pressure.  The  labia  are  in  apposition,  and 
the  fraenulum  is  intact.  The  hymen  is  torn,  but  each  fragment  re- 
mains attached  in  its  entirety  to  the  introitus  vaginas.  The  urethra 
is  hyj)ertroj)hied,  and  appears  as  a  cylindrical  body,  of  a  reddish-blue 
color,  in  the  vaginal  orifice.  The  vagina  itself  is  narrow,  with  dis- 
tinct transverse  ridges,  and  oftentimes  possesses  a  granular  feel,  from 
the  enlargement  of  the  papillae.  The  vaginal  portion  of  the  cervix 
is  soft.  When  the  head  enters  the  pelvis,  toward  the  end  of  preg- 
nancy, shortening  of  the  anterior  lip  takes  place.  The  os  externum 
is  closed,  or,  not  infrequently  toward  the  close  of  gestation,  admits  the 
passage  of  the  extremity  of  the  examining  finger.  It  then  feels  like 
a  round  opening,  with  smooth  borders,  and  a  sharp  inner  edge  at  the 
point  where  it  joins  the  cervical  mucous  membrane.  The  cervical 
canal  has  a  spindle-shape.  The  head,  in  the  latter  months,  as  a  rule, 
sinks  into  the  pelvis,  and  bulges  the  vagina. 

In  wouu'fi  who  have  already  home  chUdren  the  skin  of  the  abdo- 
men is  loose,  wrinkled,  and  can  be  gathered  into  folds  by  the  hands. 
The  uterus  is  likewise  relaxed,  and  through  its  walls  can  be  felt,  in 
many  cases,  the  projecting  parts  of  the  ftetus.  The  uterus  is  easily 
defined.  In  addition  to  the  striae  upon  the  abdomen,  noted  in  primi- 
par»,  many  of  older  date,  possessing  a  shining  white  or  silvery  ap- 
pearance, can  be  made  out.  The  breasts  are  flabby,  pendulous,  and 
marked  with  silvery  lines.  The  vulva  gapes  open,  and  wears  a  bluish 
aspect  from  the  development  of  the  superfical  veins.  The  fraenulum 
is  usually  found  to  have  been  lacerated.  The  carunculae  myrtiformes 
alone  remain  as  vestiges  of  the  hymen.*  The  vagina  is  smooth,  from 
the  obliteration  of  the  transverse  ridges.  Swelling  of  the  vaginal 
papillae  is  exceptional.  The  cervix  is  swollen,  and  has  a  cylindrical 
rather  than  a  conical  shape.  At  times  it  is  like  a  cone,  with  the  base 
downward.  The  os  is  open,  and  admits  the  extremity  of  the  finger. 
This  patulous  condition  is  due  to  lacerations  of  the  cervix,  which  are 
the  inseparable  concomitants  of  child-bearing.  The  lacerations  diSer 
greatly  in  degree,  but  are  rarely  difficult  of  recognition.  As  they  are 
situated  usually  on  the  sides  of  the  cervix,  they  convert  the  os  into  a 
wide,  transverse  slit,  bounded  by  a  well-defined  anterior  and  posterior 

*  Vide  p.  6, 


106 


PHYSIOLOGY   OF   PREGNANCY. 


lip.  The  cervical  canal  lias  a  funnel-shape,  narrowing  above.  In  the 
ninth  month  (in  some  cases  earlier)  the  finger  passes  readily  through 
the  OS  internum  to  tlie  child's  head.  The  latter  rarely  descends  into 
the  pelvis  before  the  advent  of  labor,  but  either  is  situated  at  the 
brim,  or  rests  upon  one  of  the  iliac  foss*. 

It  should  be  added,  finally,  by  way  of  caution,  that  while  the  pres- 
ence of  the  foregoing  signs  speaks  plainly  in  favor  of  the  existence  of  a 
previous  pregnancy,  their  absence  is  not  absolutely  incompatible  with 
the  occurrence  of  a  premature  labor,  or  even,  in  rare  cases,  with  the 
delivery  of  a  small  foetus  at  full  term. 

The  Diagnosis  of  thk  Death  of  the  Fcetus. 

The  presence  of  a  dead  child  /;/  utero  may  be  inferred  where  active 
movements  are  not  elicited  by  palpation,  or  where  the  heart-sounds, 
after  repeated  trials,  can  not  be  made  out.  As  we  have  seen,  a  number 
of  conditions  sometimes  combine  to  temporarily  render  it  impossible, 
even  when  the  child  is  living,  to  obtain  positive  results  by  ausculta- 
tion. A  decision  should  not,  therefore,  be  based  upon  the  results  of 
an  isolated  examination. 

In  the  earlier  months,  previous  to  the  j)eriod  wlu'n  the  fetal  heart 
can  be  heard,  the  death  of  the  foetus  is  rendered  probable  by  fial^biness 
and  diminution  in  size  of  the  uterus,  by  a  flaccid  condition  of  the 
breast,  and  certain  subjective  sensations  experienced  by  the  mother, 
such  as  languor,  chilliness,  bad  taste  in  the  mouth,  and  the  feeling 
of  a  weight  like  a  foreign  body  in  the  hyi)ogastrium.  Certainty  is 
obtained  when,  through  the  open  cervix,  the  cranial  bones  can  be 
made  out,  and  are  found  loose  and  movable  within  the  integuments. 

The  DiRATiON  of  Pregnancy. 

There  is  no  question  in  obstetrics  ujwn  the  solution  of  which  so 
much  ingenuity  has  been  expended  as  the  determining  of  the  normal 
duration  of  pregnancy.  Inasmuch  as  it  has  i)roved  imi)ossible  to 
ascertain  the  precise  moment  in.which  conception  (i.  e.,  the  fertilizing 
of  the  ovum  by  the  spermatozoa)  takes  place,  it  has  been  customary 
to  assume  as  the  starting-point  for  the  reckoning  of  gestation  either 
the  date  of  the  last  menstruation  or  that  of  a  single  fruitful  coitus. 
It  would  seem  at  first  as  though  the  latter  would  lead  us  to  more 
nearly  accurate  results.  But,  aside  from  the  fact  that  the  distance 
of  time  between  insemination  and  conception  is  avowedly  variable,* 
it  is  only  in  rare  cases  that  the  particular  coitus  which  has  resulted 
in  pregnancy  can  be  definitely  ascertained.  Duncan  collected  46  cases 
in  which  connection  took  place  during  a  single  day  only,  and  found  the 

*  Duncan,  Fecundity,  Fertility,  and  Sterility,  second  edition,  pp.  433,  435. 


THE   DIAGNOSIS   OF   PREGNANCY.  ^q'j 

average  time  to  the  date  of  parturition  was  275  days.  Ahlfeld,  from 
an  analysis  of  425  cases,  obtained  an  average  of  271  days.*  In  108 
cases  furnished  by  Hecker  the  average  was  273-52  days.f  Yeit  pub- 
lished 43  cases,  with  an  average  of  270-42  days.J  In  63  cases  of  Faye's 
the  average  was  270-G(;.*  Undoubtedly  many  of  the  cases  included  in 
these  tables  are  of  questionable  reliability;  two  of  them,  indeed,  in 
which  confinement  is  reported  to  have  followed  coitus,  respectively 
in  320  and  330  days,  evidently  belong  to  the  realm  of  fable.  Assum- 
ing, however,  that  the  size  of  the  tables  serves  to  nearly  neutralize 
specific  inaccuracies,  the  small  value  of  the  averages  obtained,  as  a 
means  of  predicting  the  date  of  confinement,  is  shown  by  the  wide 
differences  between  the  terms  of  gestation  in  the  individual  cases  of 
which  the  tables  are  composed.  Thus,  in  Ahlfeld's  table  there  existed, 
between  the  longest  and  shortest  gestation,  a  difference  of  99  days  ;  in 
Keeker's,  a  difference  of  63  days;  and  in  Yeit's,  a  difference  of  36 
days.  In  the  breeding  of  domestic  animals,  in  which  conception,  as 
a  rule,  follows  a  single  act  of  sexual  congress,  similar  variations  are 
common.  In  the  now  familiar  observations  of  Tessier,  Krahmer,  and 
Spencer,  the  average  duration  of  gestation  in  rabbits  is  31  days,  the 
variation  8  dayj ;  in  sheep,  pregnancy  averages  151  days,  and  the 
variation  amounts  to  26  days  ;  in  cows,  the  average  time  of  gestation 
is  283  days,  but  calving  may  occur  between  the  183d  and  the  356th 
day  ;  in  mares,  the  average  time  is  347  days,  but  foaling  may  occur  be- 
tween the  287th  and  the  419th  day.|| 

However,  Ahlfeld's  tables  show  that  the  bulk  of  confinements  vary 
within  narrow  limits.  Of  653  women,  in  15-93  per  cent  delivery  oc- 
curred in  the  thirty-eighth  week ;  in  27-56  per  cent,  in  the  thirty- 
ninth  week  ;  in  26-19  per  cent,  in  the  fortieth  week ;  and  in  10-01 
per  cent,  in  the  forty-first  week.  In  other  words,  more  than  half  the 
cases  occurred  in  the  thirty-ninth  and  fortieth  weeks,  and  80  per  cent 
between  the  thirty-eighth  and  forty-first  week  inclusive.  Of  the  re- 
mainder, 14  per  cent  took  place  prior  to  the  thirty-eighth  week,  and 
were  probably  influenced  by  the  many  operative  accidental  causes 
which  favor  prematurity.  Of  the  6  per  cent  reported  as  occun:ing 
later  than  the  forty-first  week,  a  considerable  number  are  of  question- 

*  Beobachtungen  iiber  die  Dauer  der  Schwangerschaf t,  Monatsschr.  f.  Geburtsk., 
Bd.  xxxiv,  p.  208.  Ahlfeld's  actual  reckoning  gave  an  average  of  269-91  days,  but 
this  was  afterward  corrected  by  Lowenhardt,  who  found  Ahlfeld's  tables  really  fur- 
nished an  average  of  270-94.  Vide  Lowenhardt,  Die  Berechnung  und  Dauer  der 
Schwangerschaft,  Arch.  f.  Gynaek.,  Bd.  iii,  p.  458. 

f  Ahlfeld,  op.  cit.,  p.  208. 

X  Ibid.,  p.  210. 

♦Other  tables  may  be  found  in  Montgomery,  Signs  of  Pregnancy,  second 
edition,  pp.  493  et  seq. 

\  Vide  Ahlfeld,  op.  cit.,  p.  216  ;  St.  Cyr,  Traite  d'obstetrique  veterinaire,  pp.  107 

et  seq. 


j^Qg  PHYSIOLOGY   OP   PREGNANCY. 

able  authenticity.     Gestation  protracted  beyond  the  two  hundred  and 
eighty-fifth  day  is  certainly  of  very  rare  occurrence.* 

Prediction  of  the  Day  of  Confinement. 

In  all  schemes  for  predicting  the  date  of  confinement,  it  is  custom- 
ary to  throw  out,  as  defying  calculation,  the  exceptional  cases,  which 
fall  much  below  or  greatly  exceed  the  usual  average.  No  scheme  is 
ever  likely  to  be  devised  which  will  insure  accuracy  with  regard  to  the 
day  upon  which  labor  will  occur.  In  every  scheme  it  has  been  assumed 
that  errors  of  from  four  to  five  days  are  inevitable.  Moral  emotions, 
fatigue,  attacks  of  indigestion,  mechanical  causes,  and  the  like,  are 
recognized  as  liable,  toward  the  end  of  gestation,  to  precipitate  labor 
at  any  time.  But  a  vast  deal  of  ingenuity  has  been  expended  in  the 
endeavor  to  reduce  ordinary  errors  within  the  narrowest  limits. 

The  Last  Menstruation. — Now,  it  has  already  been  remarked  that  it 
is  only  in  rare  cases  that  the  day  of  conception  (i.  e.,  insemination)  can 
be  utilized.  In  all  calculations  of  the  duration  of  pregnancy,  it  has 
been  customary,  therefore,  to  select  the  menstrual  period  as  the  start- 
ing-point. As  the  days  immediately  following  menstruation  are  those 
in  which  conception  usually  occurs,  the  end  of  menstruation  has  been 
adopted  by  some  as  the  most  suitable  point  of  departure.  Ahlfeld 
estimated  tliat  35-55  per  cent  of  married  women  conceived  on  the 
last  day  of  menstruation,  and  that  88-44  per  cent  conceived  within 
twelve  days,  counting  from  the  first  of  menstruation. f  Experience 
has  shown,  however,  that  there  is  no  single  day  in  the  intermen- 
strual period  in  which  conception  may  not  occur.  Jewish  women, 
indeed,  who  are  forbidden  sexual  intercourse  by  the  Mosaic  law  during 
menstruation  and  the  seven  days  following,  are  proverbially  fruitful. 
Lowenhardt  has  shown  that,  though  in  two  women  conception  follows 
in  each  a  single  act  of  coitus,  occurring  the  same  number  of  days  after 
menstruation,  there  is  no  necessary  correspondence  of  the  date  of  con- 
finement in  the  two.  J 

As,  therefore,  there  is  little  to  be  gained  by  estimating  the  day  of 
confinement  from  the  probable  day  of  conception,  it  lias  become  the 
usual  rule  to  reckon  from  the  first  rather  than  from  the  last  day  of 
menstruation,  especially  as  most  women  exercise  more  care  in  preserv- 
ing the  record  of  the  former  date. 

From  the  days  of  Hippocrates,  it  has  been   customary  to  regard 

*  Many  cases  of  apparent  protracted  gestation  find  their  exfilanation  in  the  fact 
that  conception  may  occur  just  prior  to  the  menstruation  jjeriod  succeeding  to  that 
from  which  the  count  is  made.  In  one  instance,  in  wliich  a  lady  was  confined  three 
hundred  and  six  days  after  the  last  menstrual  period,  the  statement  was  volunteered 
that  for  twenty  days  following  menstruation  "  precautions  "  against  pregnancy  had 
been  resorted  to. 

\  Ahlfeld,  op.  cit.,  p.  191.  J  Op.  cif.,  pp.  461  et  seq. 


THE   DIAGNOSIS  OF   PREGNANCY. 


109 


pregnancy  as  extending  over  ten  lunar  months,  or  ten  menstrual  pe- 
riods of  twenty-eight  days  each.  In  accordance  with  this  idea,  Nae- 
gele*  proposed  a  ready  method  of  computing  two  hundred  and  eighty 
days  from  any  given  date,  which  has  since  his  time  been  generally 
adopted.  This  consisted  in  counting  forward  nine  months,  or,  what 
amounted  to  the  same  thing,  counting  backward  three,  months,  and 
then  adding  seven^ays  (in  leap-years,  after  February,  six)  to  the  date 
chosen  as  the  starting-point  of  the  calculation.  Naegele  selected  the 
first  day  of  the  last  menstruation.  His  method  is,  of  course,  equally 
applicable,  when  the  day 
of  cessation  is  preferred  as 
the  point  of  departure.  For 
seven  months  in  the  year 
Naegele's  method  is  abso- 
lutely correct.  In  Febru- 
ary, however,  four  days,  in 
December  and  January 
five  days,  and  in  April  and 
September  six  days  only 
are  required  to  complete 
two  hundred  and  eighty 
days.  Tables  may  be  found 
in  most  physicians'  visiting 
lists,  by  means  of  which  the 
two  hundred  and  eighty 
days  may  be  determined  at 
a  glance.  The  following 
circle  of  Schultze  is  based 

upon  N^aegele's  method.  The  figures  between  the  radii  show  the  exact 
number  of  days  to  be  added  for  each  of  the  months  severally.  The 
figures  in  ])arenthese8  are  to  be  employed  in  leap-year. 

Unfortunately,  the  supposition  that  labor  comes  on  after  the  ex- 
piration of  ten  menstrual  periods  of  twenty-eight  days  each  is  correct 
for  only  a  small  number  of  cases,  so  that  it  has  been  found  necessary 
to  shift  the  ground  somewhat  to  the  position  that  the  normal  duration 
of  pregnancy  covers  ten  menstrual  periods.  The  instability  of  the 
reckoning  would  then  find  its  explanation  in  tlie  common  experience 
that  ten  consecutive  periods  of  exactly  twenty-eight  days  each  are  rare 
even  in  the  most  regular  of  women.  Although  ovulation  is  suspended 
during  pregnancy,  at  the  return  of  the  menstrual  epochs  the  existence 
of  an  ovarian  influence  upon  the  generative  organs  may  be  clearly 
traced  in  many  individuals.  At  such  times  a  sensation  of  fullness  is 
often  experienced  in  the  pelvic  organs,  associated  in  some  women  with 
an  awakening  of  the  sexual  appetite.  At  such  times,  too,  there  has 
*  Naegele,  Lehfbuch  der  Geb.,  achter  Auflage,  p.  122. 


-Diagram  for  computing  pregnancy. 
(Schultze.) 


110 


PHYSIOLOGY   OF  PREGNANCY. 


been  observed  a  tendency  to  miscarry,  so  that  it  becomes  incumbent 
upon  sensitive,  impressionable  females,  predisposed  to  abort,  to  espe- 
cially avoid  either  reflex  or  mechanical  sources  of  disturbance  during 
the  continuance  of  the  state  under  notice.  When  the  ovum  reaches 
maturity,  the  recurrence  of  the  tenth  menstrual  epoch  furnishes  local 
conditions  in  a  peculiar   degree   favoring    the   production    of    labor. 

Lowenhardt  *  found  it 
was  possible  to  calculate 
the  duration  of  preg- 
nancy in  twenty-two  in- 
dividuals with  tolerable 
accuracy,  by  assuming 
that  ten  menstrual  peri- 
ods represent  not  two 
hundred  and  eighty  days, 
but  ten  times  the  length 
of  time  between  the  last 
menstrual  period  and  the 
one  immediately  preced- 
ing it.  In  no  case  thus 
calculated  did  the  error 
exceed  five  days,  a  de- 
gree of  exactitude  un- 
attainable by  the  motbod 
of  Nacgele. 

The  Date  of  Quicken- 
ing.— Wben  the  date  of 
the  last  menstruation  can 
not    be   obtained,   it    is 
customary  to  reckon  the 
time   of   labor   approxi- 
mately by  adding  twen- 
ty-two weeks  to  the  date 
of  quickening,  which  is 
assumed  to  occur  in  the 
eighteenth  week  of  pregnancy.     The  extreme  variation,  however,  in 
the  time  at  which  quickening  occurs  in  different  individuals  renders 
this  method  of  calculation  a  very  uncertain  one. 

The  Size  of  the  Uterus. — As  the  increase  of  the  uterus  is  progress- 
ive, its  size   is  sometimes  used  in  determining  approximatively   the 

*  Die  Berechnung  und  die  Dauer  der  Schwangerschaft,  Arch.  f.  Gynaek.,  Bd.  iii, 
p.  476.  In  quite  a  number  of  instances  I  have  had  curious  confirmation  of  Liiwen- 
hardt's  theory.  Thus  I  can  recall  two  cases  where  the  menses  recurred  once  in 
twenty-six  days,  and  the  apparent  length  of  gestation  was  two  hundred  and  sixty 
days.     But  the  rule  has  many  exceptions. 


Fig.  60.— Schultze  diagram. 


THE   DIAGNOSIS   OF   PREGNANCY.  -^^^-^ 

period  to  which  gestation  has  advanced.  According  to  a  rude  for- 
mida,  commonly  employed  at  the  bedside,  the  uterus  is,  in  the  second 
month,  of  the  size  of  an  orange  ;  in  the  third  month,  of  the  size  of  a 
child's  head.  In  the  fourth  month,  it  can  be  felt  above  the  symphysis 
pubis.  In  the  fifth  month,  the  fundus  of  the  uterus  rises  to  a  point 
midway  between  the  symphysis  and  the  navel.  By  the  sixth  month, 
it  reaches  the  level  of  the  navel.  In  the  seventh  month,  it  should  be 
the  breadth  of  two  or  three  fingers  above  the  navel.  In  the  eighth 
month,  it  rises  half-way  between  the  navel  and  the  epigastrium.  In 
the  ninth  month,  it  reaches  the  epigastrium.  In  the  tenth  month, 
two  to  three  weeks  before  confinement,  the  uterus  sinks  downward  and 
somewhat  forward,  so  that  its  upper  level  corresponds  very  nearly  to 
that  of  the  uterus  in  the  eighth  month. 

In  the  foregoing  calculation  most  of  the  data  are  obtained  from  the 
relation  of  the  fundus  to  the  navel.  But  the  navel  is  not  a  fixed  point. 
Spiegelberg  found  the  distance  between  the  upper  border  of  the  sym- 
physis and  the  navel  varied  in  different  women  as  much  as  six  inches.* 
The  average  distance  from  the  symphysis  pubis  to  the  fundus  of  the 
uterus  in  the  different  months  of  pregnancy  he  found  was — 

From  the  22d  to  the  26th  week 8^  inches.f 

"  "  "       28th  week lOi  " 

"  "  "       30th  week 11  " 

"  "  "       32(1  and  33d  week Hi  <' 

"  "  "                      34th  week 12  " 

"  "  "       35th  and  36th  week 12^  " 

"  "  "       37th  and  38th  week 13  " 

"  "  "       39th  and  40th  week 13i  " 

But  the  size  of  the  uterus  is  subject  to  considerable  variations,  due 
to  the  size  of  tlie  child  and  the  amount  of  the  amniotic  fluid. 

*  Lehrbuch  der  Geb.,  Bd.  ii,  p.  115. 

f  These  measurements  exceed  considerably  those  furnished  by  Farre,  p.  83. 
The  discrepancies  are  due  in  part  to  the  extent  of  individual  variation,  and  in  part 
to  the  fact  that  they  were  made  with  a  tape-measure.  Thus,  Ahlfeld,  employing 
the  cyrtometre  of  Baudelocque,  found  the  distance  from  the  symphysis  pubis  to 
the  fundus  only  ten  and  a  half  inches  in  the  fortieth  week.  Ahlfeld  found  the 
length  of  the  child  to  be  nearly  double  the  distance  between  the  head  and  breech 
when  the  child  assumed  the  attitude  usual  in  the  uterus.  To  determine  the  date  of 
pregnancy,  he  proposed  to  measure  the  axis  of  the  foetus  in  utero,  by  means  of  a 
cyrtometre,  one  extremity  of  which,  passed  into  the  vagina,  rested  upon  the  child's 
head,  while  the  other  was  extended  to  a  mark  upon  the  abdominal  wall  correspond- 
ing to  the  breech.  He  then  sought  to  establish  the  length  of  a  child  at  each  week 
of  pregnancy.  His  tables  show,  however,  such  variations  in  the  size  of  children 
born  in  the  same  week  as  to  impair  the  practical  value  of  the  method.  Vide 
Ahlfeld,  Bestimmung  der  Grosse  und  des  Alters  der  Frucht  vor  der  Geburt,  Arch, 
f.  Gynaek.,  Bd.  ii,  p.  353. 


PREGNANCY. 


CHAPTER  VI. 

THE  MANAGEMENT  OF  PREGNANCY. 

Hygiene  of  pregnancy. — The  disorders  of  pregnancy. — The  blood-changes  of  preg- 
nancy.— Pernicious  anajmia. — Hydrasmic  oedema. — Varicose  veins. — Nausea  and 
vomiting. — Heart-burn. — Insalivation. — Pruritus. — Face-ache. — Cephalalgia. — 
Insomnia. 

In  studying  the  effects  of  pregnancy  we  saw  that,  besides  the  local 
changes  in  the  sexual  apparatus  and  the  disturbances  produced  by 
pressure,  the  organism  had  to  adapt  itself  to  a  variety  of  new  condi- 
tions, of  which  the  most  conspicuous  were  alterations  in  the  quality  of 
the  blood  and  increase  of  its  quantity,  with  additional  work  thrown 
upon  the  lungs  and  kidneys,  and  reflex  derangements  of  the  nervous 
and  digestive  systems.  The  physiological  condition  of  the  pregnant 
woman  approximates  so  closely  to  what  would  be  regarded  as  patholog- 
ical at  other  times,  that  the  necessity  arises  for  the  patient  to  carefully 
observe  hygienic  rules,  while  the  physician  often  finds  himself  called 
upon  to  exercise  his  art  in  restraining  distressing  symptoms  within 
limits  consistent  with  the  healthy  progress  of  gestation. 

The  Hygiene  o!  Pregnancy. — During  the  pregnant  state,  the  in- 
creased elimination  of  carbonic  acid  by  the  lungs  is  necessarily  associ- 
ated with  increased  consumption  of  oxygen.  This  respiratory  activity 
makes  an  abundance  of  fresh,  pure  air  a  matter  of  prime  importance. 
As  a  rule,  therefore,  a  rural  neighborliood  is  more  conducive  to  nor- 
mal pregnancy  than  large  cities.  To  be  avoided  are  small,  close,  heated 
rooms,  confinement  indoors,  and  crowded  assemblages. 

The  dietary  should  embrace  all  nutritious,  easily  digested  articles 
of  food.  The  natural  tendency  to  acidity,  heart-burn,  flatulence,  and 
colic  is  apt  to  be  increased  by  indulgence  in  the  products  of  the  frying- 
pan  and  the  dainties  of  the  pastry-cook  and  confectioner.  The  con- 
suming desire  for  unwonted  articles  of  food,  which  is  customarily 
termed  "longings,"  I  have  never  yet  witnessed,  and  am  tempted  to 
regard  as  in  a  great  measure  mythical.  A  good  appetite  is  the  best 
safeguard  against  most  of  the  discomforts  of  pregnancy.     Owing,  how- 


THE   MANAGEMENT   OF   PREGNANCY.  n^ 

ever,  to  the  activity  of  the  assimilative  processes,  a  very  moderate  ap- 
petite is  not  incompatible  with  a  considerable  gain  in  weight.  A  very 
large  appetite  is  not  normal  during  pregnancy,  and  requires  to  be 
restrained. 

The  dress  should  be  loose  and  easy.  Garters  and  tight  corsets 
should  be  discarded.  When  the  projection  of  the  abdomen  removes 
the  folds  of  the  dress  from  the  lower  limbs,  flannel  drawers  reaching 
to  the  waist  should  be  worn  as  a  protection. 

Gentle  exercise,  not  pushed  to  the  verge  of  fatigue,  should  be  en- 
couraged. Walks  and  drives  in  the  fresh  air  are  the  best  means  of 
fostering  sleep  and  maintaining  the  appetite  and  general  assimilative 
processes.  Violent  exercise,  on  the  other  hand,  is  liable  to  produce 
miscai'riage.  It  is  stated  that  the  predisposition  to  miscarriage  is 
greatest  at  the  third  and  seventh  months.  Throughout  pregnancy 
special  care  should  be  observed  at  the  recurrence  of  the  menstrual 
epochs.  Long  railway  Journeys  at  such  times  are  a  frequent  cause  of 
trouble.  Marital  relations,  though  not  absolutely  to  be  prohibited, 
should  be  of  infrequent  occurrence.  Excesses  in  the  newly  married 
are  a  common  source  of  abortion. 

The  skin  should  be  kejit  in  good  condition  by  frequent  bathing,  as 
by  its  eliminative  action  it  is  capable  of  relieving  the  kidneys  of  a  por- 
tion of  the  work  thrown  upon  them.  The  increased  vaginal  secretion 
renders  it  important  for  the  woman  to  frequently  wash  the  external 
genitals.  Tlie  vaginal  douche  is  a  source  of  comfort  to  many  women, 
but  the  quantity  injected  should  not  exceed  a  pint  of  water,  and  should 
be  introduced  slowly,  with  every  precaution  in  the  way  of  allowing  an 
immediate  reflux  to  take  place. 

The  increased  irritability  often  observable  in  pregnant  women  calls 
for  the  greatest  forbearance  and  gentleness  on  the  part  of  those  who 
are  brought  into  close  contact  with  them.  Their  unreasonableness  is 
not  to  be  cured  by  either  impatience  or  stern  treatment.  It  is  the 
product  of  nervous  derangement,  and  is  to  be  regarded  as  due  rather  to 
physical  than  to  moral  fault. 

The  Disorders  of  Pregnancy.— Among  women  reared  amid  the 
Tefinements  of  civilization  the  entire  period  of  pregnancy  is  very  fre- 
quently attended  with  a  great  deal  of  discomfort.  The  attempt  to 
relieve  the  disorders  of  pregnancy  seriatim,  it  should  be  stated  in  a 
general  way,  is  a  vain  undertaking,  and  is  a  good  method  to  beget  hys- 
teria by  fixing  the  female's  attention  upon  minor  ailments.  The  best 
medicines,  in  a  large  proportion  of  cases,  are  amusements  and  occu- 
pations calculated  to  produce  a  forgetfulness  of  self.  When,  how- 
ever, the  disorders  of  pregnancy  advance  beyond  the  stage  of  dis- 
comfort to  that  of  actual  suffering  or  danger,  every  effort  should  bo 
put  forth  for  their  relief  or  mitigation. 

The  Blood-Changes  of  Pregnancy.— Under  ordinary  physiological 


^^^  PREGNANCY. 

conditions,  as  we  have  noted,  there  is  a  natural  increase  of  the  red 
corpuscles  in  the  blood  during  pregnancy  ;  but  as  a  consequence  of 
faulty  food  assimilation,  or  of  penury  and  want,  there  may  be  a  loss  of 
/red  corpuscles  and  of  albumen.  The  red  blood-corpuscles,  as  the 
■^  oxygen-carriers  to  the  tissues,  are  illy  spared  from  the  economy.  "When 
they  have  undergone  destruction  to  any  material  extent,  the  cell-ele- 
ments, whose  vitality  is  intimately  associated  with  the  power  to  take 
oxygen  from  the  blood,  suffer  from  inanition,  and  the  starved  cells 
waste  or  fill  with  fatty  molecules.  These  changes  are  of  necessity  fol- 
lowed by  loss  of  weight,  muscular  prostration,  impaired  functional 
activity  of  the  secretory  organs,  and  increased  nerve  irritability.  As  a 
consequence,  the  appetite  fails,  the  digestion  is  weakened,  neuralgic 
pains  develop,  and  even  moderate  muscular  exertion  is  attended  with 
effort  and  followed  by  a  sense  of  fatigue  ;  vertigo,  loss  of  memory,  and, 
in  severe  cases,  chorea,  hysteria,  and  insanity,  may  result  from  the 
deranged  condition  of  the  nerve-centers ;  attacks  of  syncope,  palpita- 
tions, and  precordial  oppression  point  to  feeble  heart-action  ;  the  arte- 
rial tension  is  lowered  and  venous  hyperemia  results ;  and,  finally,  the 
stagnant  blood,  deprived  of  its  albumen,  in  place  of  inviting  endos- 
motic  currents,  transudes  through  the  walls  of  the  vessels,  giving  rise 
to  oedema  and  dropsical  effusions.  Gusserow*  (1871)  called  attention 
to  the  fact  that  the  anemia  of  pregnancy  might  progress  to  such  an 
extreme  as  to  produce  a  fatal  termination. 

The  treatment  of  anemia  is  largely  prophylactic.  Light,  air, 
moderate  exercise,  good  food,  regulation  of  the  bowels,  cheerful  society, 
and  an  occasional  respite  from  household  and  family  cares,  will  always 
be  the  main  checks  to  its  extreme  development.  Iron,  though  of  little 
avail  in  repairing  losses  which  have  already  taken  place,  is  of  the  ut- 
most value  in  limiting  the  progress  of  the  malady.  Iron  reduced  by 
hydrogen,  in  three-grain  doses,  either  alone  or  combined  with  a  fiftieth 
of  a  grain  of  arsenic,  has  rendered  me  most  service  in  this  affection. 
It  should,  however,  be  continued  without  intermission  for  weeks  at  a 
time  in  order  to  obtain  the  full  advantage  of  its  beneficent  action. 
The  liquid  forms  of  iron,  so  useful  at  other  times,  I  have  rarely  found 
tolerated  for  a  lengthened  period  in  the  pregnant  state.  In  weakened 
states  of  the  stomach,  when  the  latter  revolts  at  beefsteak  and  mutton, 
easily  assimilated  albuminoid  articles,  such  as  milk,  soft-boiled  eggs, 
and  scraped  raw  or  underdone  meat,  should  be  administered  in  small 
but  frequently  repeated  portions.  Where  the  marasmus  is  extreme, 
and  the  rectum  tolerant,  the  stomach  may  be  relieved  of  a  part  of  its 
duty  by  the  use  of  nutritive  enemata  prepared  in  accordance  with  the 
now  familiar  prescription  of  Leube.  In  the  pernicious  form  of  anaemia, 
Gusserow  tried  transfusion,  but  without  success.     He  recommended, 

*  Gusserow,  Ueber  hochgradigste  Anaemie  Schwangerer,  Arch.  f.  Gynaek.,  Bd. 
ii,  p.  218. 


THE   MANAGEMENT   OP  PREGNANCY.  II5 

therefore,  the  resort  to  premature  labor.  In  a  case  wliich  occurred  to 
me  in  hospital  practice,  before  my  attention  was  drawn  to  Gusserow's 
essay,  I  employed  tlie  latter  method  after  consultation  with  my  col- 
leagues. The  patient  made  a  slow  but  apparently  sure  progress  to- 
ward recovery,  until,  at  the  end  of  a  month,  she  managed,  in  the  tem- 
porary absence  of  the  ward  nurse,  to  get  out  of  bed  and  make  a  hearty 
meal  of  corned  beef  and  cabbage.  Vomiting  set  in,  followed  by  col- 
lapse, which  proved  fatal  in  a  few  hours.  This  pernicious  form  of 
ana?mia,  though  not  confined  to  multiparte,  develops  most  frequently  in 
Avomen  who  have  borne  many  cliildren  in  rapid  succession. 

A  not  unusual  result  of  hydraemia  consists  in  a  swelling  of  the 
lower  extremities,  beginning  at  the  ankles,  and  thence  extending  up- 
ward and  invading  often  the  labia,  the  vagina,  and  the  lower  segment 
of  the  uterus.  When  not  associated  with  kidney  comjilications,  this 
oedema  is  rarely  dangerous,  though  often  the  source  of  extreme  dis- 
comfort. In  some  cases  of  oedema  of  the  vulva,  the  labia  may  attain 
to  the  size  of  a  man's  head,  and  become  nearly  diaphanous  from  the 
serous  infiltration.  When  the  distention  is  extreme,  gangrene  may 
threaten  and  make  it  necessary  to  resort  to  puncture.  In  lying-in 
hospitals  this  should  be  done  with  every  antiseptic  precaution.  With 
free  drainage  established,  the  swelling  rapidly  subsides.  In  a  half- 
dozen  cases  which  I  have  thus  far  treated  in  this  manner,  premature 
labor  has  followed  in  the  course  of  two  or  three  days — a  coincidence  of 
such  frequent  occurrence  as  to  make  it  necessary  to  employ  puncture 
with  circumspection. 

(Edema  of  the  lower  extremities  seldom  disappears  entirely  before 
confinement,  though  relief  is  sometimes  experienced  in  the  last  month, 
when  the  fundus  of  the  uterus  falls  forward.  Slight  degrees,  such  as 
swelling  limited  to  the  feet,  making  it  necessary  for  the  woman  to  go 
around  in  old  shoes  or  her  husband's  slippers,  do  not  require  treat- 
ment. Where,  however,  the  skin  of  the  limbs  becomes  tense  and 
painful,  warm  cloths  should  be  applied,  diaphoresis  if  possible  should 
be  induced,  tonics  should  be  administered,  and  the  patient  be  kept  in 
a  recumbent  position,  or  with  the  extremities  raised  a  VAmericaine. 
Hydragogue  cathartics,  by  still  further  impovishering  the  blood,  tend 
to  aggravate  the  difficulty. 

Varicose  Veins. — Varicose  veins  occur  with  greater  frequency  in 
multipara?  than  in  primiparae.  So  long  as  the  large  veins  are  not 
involved,  they  possess  slight  significance.  The  saphena  is  always  first 
affected,  then  the  lateral  branches  upon  the  inner  surface  of  the  leg 
and  thigh,  especially  just  above  the  knee,*  and  less  commonly  the 
veins  of  the  vulva.  Dilatation  of  the  haemorrhoidal  veins  is  a  very 
frequent  occurrence. 

The  treatment  of  varicose  veins  is  limited  to  the  adoption  of  meas- 

*  Spiegelberg,  loc.  cit.,  p.  250. 


^-^Q  PREGNANCY. 

Tires  to  prevent  their  increase,  and  to  i)rovide  against  the  dangers  of 
rupture.  The  first  indication  is  best  fulfilled  by  regulation  of  the  bow- 
els and  the  wearing  of  elastic  stockings.  The  subcutaneous  injection  of 
one  to  two  grains  of  ergotin  in  solution  has  been  recommended,  and  is 
reported  not  to  awaken  uterine  contractions.  As  the  danger  of  rupture 
is  not  speculative  (Spiegelberg  *  reports  two  cases  of  fatal  haemorrhage 
from  this  cause),  the  patient  should  always  be  provided  with  a  com- 
press and  bandage,  which  she  should  be  taught  to  apply  herself  in  case 
of  a  sudden  emergency  before  professional  aid  can  be  obtained. 

Nausea  and  Vomiting. — There  are  few  known  therapeutical  agents 
which  have  not  at  one  time  or  another  been  essayed  as  remedies  for 
the  nausea  and  vomiting  of  pregnancy.  Some  of  them  have  even  en- 
joyed for  a  time  high  repute  as  specifics,  but  the  sobering  effect  of 
experience  has  invariably  served  to  dispel  illusive  hopes,  the  most  suc- 
cessful of  them  proving  uncertain,  and  of  benefit  to  only  a  limited 
class  of  patients.  It  is  usually,  therefore,  the  part  of  prudence  to  do 
nothing  for  the  minor  degrees  of  the  affection,  such  as  the  ordinary 
morning-sickness,  or  even  for  continuous  nausea,  so  long  as  the  inges- 
tion of  food  and  the  general  nutrition  of  the  patient  are  undisturbed. 
For  these  cases  Seyfert's  advice,  to  let  the  wife  go  home  on  a  visit  to 
her  mother,  implying  the  value  of  changed  surroundings,  furnishes  a 
serviceable  hint  in  the  way  of  practice.  When,  however,  the  distress- 
ing symptoms  continue  after  the  first  three  months,  and  perceptibly 
tend  to  exhaust  the  vital  powers,  every  resource  should  be  tried  in 
turn,  in  the  hope  that  some  one  of  the  many  in  repute  may  prove  of 
service  as  a  means  of  warding  off  impending  disaster. 

At  the  outset  of  any  systematic  jilan  of  treatment  for  pregnancy- 
vomiting,  it  is  essential  that  the  physician  should  inspire  his  patient 
with  confidence  in  his  ultimate  success.  Care  should  be  taken  to  reg- 
ulate the  bowels,  as  constipation  invariably  aggravates  existing  gastric 
disturbance.  Coitus  often  increases  the  sickness.  If,  in  the  early 
months,  the  uterus  is  found  retroverted  or  retrofiexed,  it  should  be  re- 
placed in  the  knee-chest  position,  and  the  recurrence  of  the  displacement 
should  be  prevented  by  a  suitable  pessary.  Grailly  Hewitt  has  likewise 
called  attention  to  the  fact  that  pregnancy-sickness  may  coexist  with 
impaction  of  the  uterus  connected  with  marked  anteflexion.  In  such 
cases  relief  is  sometimes  afforded  by  elevating  the  patient's  hips  and 
by  pushing  the  fundus  of  the  uterus  upward  with  the  finger.  If 
necessary,  the  replacement  should  be  maintained  by  cotton  pledgets,  or 
by  Gariel's  air  pessary  A  speculum  examination  should  be  made  of 
the  cervix,  and,  should  it  be  found  eroded,  the  raw  surface  should  be 
brushed  at  intervals  of  from  two  to  three  days  with  a  ten-per-cent 
solution  of  nitrate  of  silver.      Collins  (Lancet,  Dec.  17,   1887)   has 

*  Ibid,,  p.  250.  For  a  complete  discussion  of  the  subject,  t%de  Des  varices  chez 
la  femme  enceinte,  These  d'Agregation,  par  le  Dr.  P.  Budin. 


TPIE   MANAGEMENT   OF   PREGNANCY.  217 

caused  the  cessation  of  vomiting  by  a  single  application  to  the  cervix 
of  a  ten-per-cent  cocaine  salve  by  means  of  a  cotton  tampon.  In  quite 
a  number  of  cases  a  mitigation  of  the  distress  is  obtained  by  applyino- 
the  faradaic  current  to  the  pit  of  the  stomach ;  in  others,  the  ice-bao- 
applied  to  the  cervical  vertebra?  affords  a  considerable  measure  of 
relief ;  and  again  in  still  others  the  sickness  is  helped  by  spraying  the 
pit  of  the  stomach  with  ether.  In  hysterical  patients  Doleris  recom- 
mends the  shower-bath.  The  inhalation  of  oxygen  has  likewise  been 
tried  by  Pinard  with  success.  To  many,  ice-cold  effervescent  drinks  are 
grateful.  Dr.  Fordyce  Barker  was  wont  to  recommend  carbonic-acid 
water  containing  a  drachm  of  bromide  of  potassium  to  the  siphon. 
Dry  champagne  is  of  assistance  to  a  comparatively  small  class,  but 
more  often  I  have  found  it  revolting  to  a  squeamish  stomach.  Of 
medicinal  agents,  subnitrate  of  bismuth  and  the  oxalate  of  cerium  pos- 
sess the  widest  application.  Usually  I  order  ten  grains  of  the  former, 
combined  with  five  to  ten  grains  of  the  latter,  to  be  taken  ten  minutes 
before  eating.  In  cases  of  gastric  catarrh,  my  favorite  is  the  tincture 
of  nux  vomica  given  in  ten-drop  doses  before  meals.  Drop  doses  of 
Fowler's  solution  at  meal-time  are  said  to  exert  considerable  influence 
in  allaying  stomach  irritability.  A  twelfth  of  a  grain  of  morphia  given 
hypodermically  or  by  the  mouth  will  frequently  aid  the  retention  of 
food  by  the  stomach,  but  may  lead  to  the  formation  of  the  opium  habit. 
Simmons,  of  Yokohama,  advises  the  injection  of  thirty  grains  of  chloral 
per  rectum  morning  and  evening,  a  practice  of  which  Richardson  ad- 
vises ftirther  trial.*  After  eating,  digestion  may  be  promoted  by  ten 
grains  of  pepsin,  given  alone  or  with  either  the  dilute  muriatic  acid 
or  Horsford's  acid  phosphate.  Gunther  f  states  that  he  has  caused 
the  cessation  of  vomiting  by  the  use  of  galvanism  as  follows :  He  placed 
the  anode  covered  by  a  sponge  to  the  cervix,  and  the  cathode,  by 
means  of  a  large  plaque,  4x8  inches,  over  the  spine,  between  the  eighth 
and  twelfth  vertebri^i.  In  no  case  did  the  vomiting  persist  more  than 
five  days.  The  strength  of  the  current  was  at  first  2i  to  3  milli- 
amperes,  and  never  exceeded  5  milliamperes. 

If  the  foregoing  measures  prove  of  no  avail,  the  patient  should  be 
made  to  take  small  quantities  of  easily  digested  food,  such  as  milk  and 
lime-water,  koumyss,  Valentine's  beef-juice,  or  the  pulp  scraped  from 
raw  or  underdone  beef,  at  hourly  intervals,  while  rest  in  bed  is  maintained 
for  the  purpose  of  avoiding  the  slightest  unnecessary  waste  of  tissue. 

In  very  rare  instances  the  vomiting  becomes  incessant,  and  resists 
every  remedy.  If  death  from  starvation  threatens,  it  may  become 
necessary,  as  an  ultimate  resource,  to  terminate  pregnancy  by  artifi- 
cial  means.     The   severest   cases  rarely  are   such  at  the  beginning. 

*  Richardson,  Hydrate  of  Chloral  iu  Obstetric  Practice,  Trans,   of  the  Am. 
Gynsec.  Soe.  vol.  i,  p.  347. 

t  Centralblatt,  1888,  p.  465. 


^1^  PREGNANCY. 

Usually,  at  the  outset,  there  is  a  period  of  nausea,  followed  by  occa- 
sional  attacks  of  easy,  painless  vomiting.  But  in  time  everything 
taken  into  the  stomach  is  rejected.  The  patient  experiences  a  disgust 
for  all  food,  or,  rarely,  a  craving  for  indigestible  articles  of  diet.  With 
this  condition  is  often  associated  pains  in  the  stomach  and  profuse 
salivation;  constipation  is  common;  diarrhoea  is  the  exception.  Ac- 
cording to  Horwitz,  patients  sometimes  complain  of  unpleasant  odors 
(hyperosmia).  With  the  constant  vomiting,  they  become  wasted,  pale, 
and  apathetic.  As  exhaustion  becomes  marked,  the  pulse  grows  weak 
and  rapid ;  the  respirations  are  more  frequent ;  the  skin  of  the  body 
becomes  dry  and  hard ;  the  extremities  are  cold  and  blue,  and  at  times 
are  covered  with  sweat.  Xow  and  then  a  slight  elevation  of  tempera- 
ture is  observable.  The  vomited  matter  consists  of  mucus  mingled 
with  bile,  and  is  sometimes  tinged  with  blood.  Toward  the  end  con- 
stant thirst  is  felt,  the  mouth  and  throat  are  dry,  the  buccal  mucous 
membrane  is  reddened,  the  tongue  is  red  at  the  tip  and  brown  at  the 
root,  sordes  cover  the  gums  and  the  teeth,  and  the  breath  has  a  most 
disgusting  odor.  The  quantity  of  the  urine  sinks  to  a  few  ounces  daily, 
is  concentrated,  and  contains  both  albumen  and  casts,  the  latter  ordi- 
narily epithelial,  but  sometimes  fibrinous.  To  the  close  of  life  extreme 
emaciation  and  weakness  ensue,  the  face  is  pinched,  the  eyes  are  dull 
and  sunken,  fainting  attacks  are  frequent,  the  sensorium  is  sometimes 
unobscured,  but  often  there  are  hallucinations  and  tlelirium.  Before 
life  closes  the  vomiting  ceases. 

Remissions  in  the  course  of  the  disease  are  not  uncommon.  Some- 
times the  strength  holds  out  to  the  end  of  pregnancy.  The  fatus  in 
these  cases  suffers  but  little  from  the  exiiaustion  of  the  mother.  In 
general,  however,  the  prognosis  is  bad.  Joulin  has  reported  one  hun- 
dred and  twenty-one  cases,  with  forty-nine  deaths.  Without  treat- 
ment, of  fifty-seven  cases,  twenty-eight  were  fatal ;  with  treatment 
(abortion  induced),  of  thirty-six  patients,  nine  only  died. 

The  treatment  consists  first  in  the  careful  removal  of  all  compli- 
cating conditions.  In  the  early  stages  it  may  be  sufficient  to  resort  to 
the  measures  already  recommended.  If  the  vomiting  is  literally  un- 
controllable, the  patient  should  be  placed  at  rest  in  bed.  Every  un- 
necessary movement  should  be  avoided.  Horwitz  recommends  that 
the  room  be  darkened,  and  in  advanced  cases  that  warmth  be  applied 
to  the  body.  Rectal  alimentation  is  often  capable  of  rendering  excel- 
lent service.*     Peptonized  milk,  defibrinated  blood,t  and  the  beef  and 

*  Dr.  BusEY,  in  an  article  published  in  the  Am.  Jour,  of  the  Med.  Sci.  (1879,  pp. 
112-117),  advises  stomach-rest,  nutritive  eneraata,  and  the  rectal  administration  of 
bromide  of  potassium.  Later  experiences  have  fully  confirmed  the  value  of  his 
recommendations. 

t  We  owe  this  excellent  suggestion  to  Dr.  A.  H.  Smith.  The  defibrinated  blood 
should  be  administered  warmed,  three  to  four  ounces  at  a  time,  once  in  eight  hours. 


THE  MANAGEMENT  OF  PREGNANCY.  ^^ 

pancreas  solution  of  Leube,*  may  be  used  for  this  purpose.  The  quan- 
tity should  not  exceed  four  to  six  ounces,  and  should  not  be  repeated 
more  frequently  than  three  to  four  times  in  twenty-four  hours.  Some- 
times it  is  necessary  tliat  the  stomach-rest  sliould  be  absolute.  It  is 
however,  permissible  for  the  patient  to  ease  her  thirst  with  bits  of  ice 
or  small  quantities  of  sparkling  drinks  when  they  are  not  immediately 
ejected.  If  the  latter  is  the  case,  I  administer  eight  ounces  of  water 
with  the  addition  of  two  whites  of  eggs,  per  rectum  three  times  daily, 
in  addition  to  the  regular  enemas.  Usually  it  will  be  necessary  to 
quiet  the  nervous  system  by  some  anodyne  agent.  Dr.  Busey  recom- 
mends the  rectal  administration  of  bromide  of  potassium.  Horwitz 
and  Sutugin  press  the  claims  of  chloral.  Codeia  by  the  mouth  and 
morphia  hypodermically  are  of  undoubted  service  in  many  cases. 
But  the  choice  will  have  to  be  determined  by  the  idiosyncrasy  of  the 
patient. 

After  the  regular  continuance  for  a  few  days  of  the  rectal  alimen- 
tation, attempts  should  be  made  to  test  the  capacity  of  the  stomach  to 
retain  solid  food.  Sutugin  got  good  results  from  little  balls  of  meat 
which  he  had  cooked  over  a  spirit-lamp.  Small  quantities  of  pepto- 
nized milk,  or  paucreatized  solutions  of  meat,  should  be  tried,  though 
sometimes  indigestible  articles  of  food  are  found  to  be  those  which  are 
really  best  tolerated. 

Dr.  Henry  F.  Campbell  f  relates  a  case  where  he  nourished  a  pa- 
tient fifty-two  days  by  the  rectum  alone.  Such  cases  are  very  rare, 
owing  to  the  fact  that  in  time  the  rectum  becomes  intolerant  of  the 
presence  of  injected  materials.  If,  therefore,  the  rectal  method  of 
nutrition  fails  to  relieve  the  patient,  the  induction  of  abortion  or  pre- 
mature labor  should  be  resorted  to  before  the  stage  of  extreme  inan- 
ition is  reached.  But  first  in  such  a  case  it  is  well  to  recall  the  expe- 
rience of  Dr.  Copeman,  of  Norwich,  England.  Desirous  of  exciting 
abortion  (patient  at  sixth  month),  he  pushed  his  finger  upward  through 
the  cervix  to  the  membranes.  These  he  tried  to  rupture  with  a  sound, 
but  without  success.  Two  hours  later  he  returned  to  his  patient,  and 
found,  to  his  astonishment,  the  vomiting  had  ceased.  Later  he  tried 
the  plan  of  dilating  the  os  externum  and  cervix  with  the  index-finger 
for  the  cure  of  persistent  vomiting,  and  in  four  cases  he  succeeded  by 
this  method  in  removing  the  distressing  symptom.     In  three  subse- 

To  prevent  decomposition,  Dr.  Smith  advises  the  addition  of  a  grain  and  a  iialf  of 
chloral  to  each  fluidounce  of  the  blood. 

*  Leube's  formula  consists  of  five  to  ten  ounces  of  finely  chopped  beef,  to  which 
should  be  added  one  third  its  weight  of  finely  minced  pancreas  (pig  or  ox).  The 
mixture  should  be  treated  in  a  mortar  with  five  ounces  of  lukewarm  water,  and  re- 
duced to  a  thick  soup  (Foster's  Clinical  Medicine,  p.  24).  Not  more  than  four  to 
six  ounces  should  be  given  at  a  time,  nor  more  frequently  than  once  in  four  hours. 

t  H.  F.  Campbell,  Rectal  Ahmentation  in  Pregnancy,  Trans,  of  the  Am.  Gyn. 
See.,  vol.  iii,  p.  273. 


^20  PREGNANCY. 

quent  trials  he  found  that  it  was  not  necessary  to  press  up  to  the  os  in- 
ternum, but  that  it  sufficed  to  pass  the  index-finger  to  the  first  joint. 
Rosenthal  has  since  reported  two  favorable  cases.  Dr.  AV.  Gill  Wylie  * 
believes  that  most  cases  of  nausea  may  be  cured  by  Copeman's  method 
combined  with  treatment  of  any  discoverable  cervical  lesion.  He  has 
devised  a  special  steel  dilator  to  take  the  place  of  the  finger.  His  de- 
scription of  his  plan  of  conduct  is  as  follows  : 

"  The  vulva  and  vagina  are  carefully  washed  with  a  l-to-3,000  solu- 
tion of  mercuric  bichloride.  I  then  dip  the  blades  of  my  dilator  in  pure 
carbolic  acid  and  shake  off  the  free  acid  and  introduce  the  points  into 
the  cervix  for  about  half  an  inch,  a»d  slowly  dilate  until  the  blades 
separate  from  one  third  to  one  half  an  inch.  If  there  is  an  eroded  or 
everted  diseased  tissue  present,  I  touch  it  lightly  with  an  applicator  that 
has  been  dipped  in  pure  carbolic  acid.  I  then,  with  a  powder-blower, 
cover  the  cervix  with  a  thin  layer  of  iodoform,  and  place  against  the 
cervix  a  flat  pledget  of  borated  absorbent  cotton  soaked  in  pure  glycer- 
in, which  is  to  be  removed  in  twenty-four  hours  by  means  of  a  short 
string  attached  to  it.  In  some  cases  there  is  slight  j^ain,  but  in  most 
cases  no  pain  or  real  disturbance  whatever  is  produced.  As  a  rule, 
this  will  relieve  nausea ;  but  after  four  or  five  days,  if  there  is  still 
nausea,  I  repeat  the  dilatation,  and  may  pass  the  dilator  three  fourths 
of  an  inch,  and  in  some  cases,  where  the  cervix  is  long,  even  more. 
Very  rarely  will  more  than  two  dilatations  be  needed.  In  some  cases 
the  cervix  is  so  patulous  that  dilatation  may  seem  to  be  useless,  but 
well  up  in  the  cervix  tight  bands  may  be  found,  and,  when  stretched, 
complete  relief  is  effected.  Even  where  the  cervix  is  lacerated  and 
apparently  open,  bands  may  be  found,  and,  when  stretched,  relief  is 
obtained.  It  is  easy  in  such  cases  to  recognize  when  the  end  of  the 
dilator  comes  against  the  os  internum,  for  it  is  firmly  closed,  and  by 
passing  the  instrument  until  the  os  is  felt,  and  then  slightly  withdraw- 
ing it,  dilatation  can  be  done  without  much  risk.  In  severe  cases  the 
cervix  may  be  of  a  very  bluish-black  color.  The  glycerin  application 
causes  a  free  watery  discharge,  and  relieves  this  congestion.  Formerly 
I  used  nitrate  of  silver  for  granular  erosion,  but  I  found  that  the  car- 
bolic acid  and  glycerin  had  an  equally  good  effect." 

Horwitz  was  less  fortunate ;  still,  the  trial  of  the  measure  is  justi- 
fiable, inasmuch  as  its  failure  does  not  aggravate  the  patient's  discom- 
fort, and  does  not  measurably  delay  the  resort  to  the  artificial  inter- 
ruption of  pregnancy.  By  the  latter  method,  McClintock  reports  in 
thirty-six  cases  the  saving  of  twenty-seven  lives.  It  is  obvious  that 
the  results  are  mainly  determined  by  the  condition  of  the  patient  at 
the  time  the  operation  is  undertaken.  In  the  advanced  stages  of  the 
disease,  after  the  tongue  has  become  dry  and  brown,  the  urine  scanty 
and  albuminous,  and  when  the  wasting  and  prostration  have  reached 
*  Wylie,  Vomiting  in  Pregnancy,  N.  Y.  Med.  Record,  Dec.  6,  1884. 


THE  MANAGEMENT  OF   PREGNANCY.  i^)-^ 

an  extreme  degree,  it  is  hardly  to  be  expected  that  many  lives  are  to 
be  rescued.* 

For  the  induction  of  abortion  in  the  early  months  I  prefer  the 
tupelo  tents,  as,  with  the  softening  and  dilatation  caused  by  the  tents,  the 
sickness  usually  ceases  for  a  considerable  period  previous  to  expulsion 
of  the  ovum. 

In  deciding  the  question  of  abortion,  it  is  necessary  not  to  forget  the 
neurotic  character  of  the  stomach  sickness  in  many  pregnant  women.  The 
comj^lcte  cessation  of  the  vomiting,  deemed  uncontrollable  as  the  result  of 
mental  impressions,  has  been  often  noted  by  clinical  observers.  In  one  instance, 
owing  to  extreme  exhaustion  of  the  patient  due  to  continued  vomiting,  I  de- 
cided to  induce  abortion.  As  I  was  making  preparations  to  that  end,  the 
patient,  somewhat  unexpectedly  to  myself,  announced'  her  determined  opposi- 
tion to  the  proposed  plan  of  treatment.  I  endeavored  to  show  her  that  it  was 
necessary,  to  save  her  life.  She  asked  me  to  hand  her  a  cup  of  bouillon.  As 
she  swallowed  it  I  told  her  there  would  be  no  occasion  to  induce  abortion,  if 
she  kept  it  on  her  stomach.  This  she  did  seemingly  without  difficulty,  and 
from  tiiat  moment  to  the  end  of  the  pregnancy  there  was  no  recurrence  of 
stomach  sickness.  A  similar  history  is  related  by  Kaltenbach.t  In  a  paper  on 
the  excessive  vamiting  of  pregnancy,  Kaltenbach  urges  that  in  all  cases 
especial  stress  should  be  laid  upon  the  underlying  disturbance  of  the  nervous 
system.  With  this  object  in  view,  he  recommends  that  the  physician  should 
seek  to  win  the  confidence  of  his  patients  in  respect  to  methods  of  treatment 
prescribed  and  the  efficacy  of  remedies  employed.  Often,  to  secure  favorable 
results,  it  becomes  necessary  to  isolate  the  sufferer  from  anxious  and  in- 
judicious friends,  and  from  the  petty  irritations  of  domestic  life.  "The  more 
authoritatively  the  2)hysician  carries  out  his  plans  of  treatment,"  he  says,  "the 
more  rarely  will  he  be  driven  to  seek  a  cure  in  artificial  abortion." 

Heart-bum. — Heart-burn  becomes  distressing  in  the  later  months 
of  pregnancy.  It  can  rarely  be  cured  before  delivery,  but  may,  in 
most  cases,  be  palliated  by  carbonate  of  magnesia  or  half-teaspoonful 
doses  of  aromatic  spirits  of  ammonia. 

Salivation. — Excessive  flow  of  saliva  to  the  extent  of  two  to  three 
quarts  in  the  course  of  the  day  has  been  observed.  For  this  dis- 
order small  doses  of  atropia,  the  twelfth  of  a  grain  of  pilocarpine,  and 
the  fluid  extract  of  viburnum  prunifolium  have  been  severally  recom- 
mended. 

Pruritus.— Pruritus,  without  any  visible  affection  of  the  skin, 
Bometimes  occasions  in  pregnant  women  an  unendurable  degree  of 
suffering.  When  general,  temporary  relief  may  be  obtained  by  plac- 
ing the  patient  in  a  prolonged  soda-bath,  and  subsequently  rubbing 
the  entire  surface  with  vaseline.     Very  commonly  the  itching  is  con- 

*  For  recent  discussions  of  this  subject,  vide  Horwitz.  Ueber  das  unstillbare 
Erbrechen  der  Schwangeren,  Ztschr.  f.  Geburtsk.  und  Gynaek.,  vol.  ix.  p.  110. 
SuTUGiN,  Hyperemesis  gravidarum,  Berlin,  1883. 

t  Kaltenbach,  Ueber  Hyperemesis  gravidarum,  Ztschr.  fur  Geburtsk.  und 
Gynaek.,  Bd.  xxi,  p.  200. 


^22  PREGNANCY. 

fined  to  the  distended  abdominal  walls.  In  such  cases,  cloths  wet 
with  camphor  liniments,  with  the  addition  of  chloroform  (lin.  saponis 
comp.,  1  V ;  chloroform,  I  j),  or  a  solution  of  carbolic  acid  (  3  j  ad 
Oj),  applied  to  the  itching  surface  will  usually  allay  the  irritation  for 
the  time.  In  pruritus  of  the  vulva,  in  addition  to  local  external  ap- 
plications, great  care  should  be  taken  to  cleanse  the  vagina  with  so- 
lutions of  borax  or  carbolic  acid.  A  half-pint  slowly  injected  into  the 
vagina  may  be  employed  twice  daily,  without  risk  of  provoking  labor. 
If  the  itching  results  from  an  acrid  discharge  proceeding  from  an 
ulcerated  cervix,  the  application  of  nitrate  of  silver,  or  the  introduction 
at  night  of  a  cotton  plug  soaked  in  a  solution  of  tannin  in  glycerin 
(ac.  tannic,  3  J  ;  glycerinae,  3  j),  will  usually  aiford  relief. 

Face-ache. — Neuralgia  of  the  fifth  nerve  is  a  common  affection  in 
pregnant  women.  It  can  often  be  quieted  by  the  external  application 
of  aconite,  chloroform,  or  camphor  liniment.  Should  these  or  kindred 
remedies  fail,  it  is  best  to  resort  at  once  to  the  hypodermic  injection 
of  morphia.  The  recurrence  of  i)ain,  as  the  effects  of  the  morphia 
pass  away,  can  in  most  cases  be  prevented  by  giving  to  the  patient 
once  in  four  hours  from  three-  to  five-drop  doses  of  the  fluid  extract  of 
gelsemium,  suspending  its  administration  so  soon  as  the  slightest  in- 
dication of  ptosis  is  produced.  Croton-chloral,  in  from  two-  to  five- 
grain  doses  hourly,  has  likewise  proved  effective.  Bartholow  advises 
not  to  push  •  the  remedy  beyond  fifteen  grains.  Lindner  (Arch.  f. 
Gynaek.,  Bd.  xvi,  p.  312)  recommends  ten  grains  at  a  dose  given  at 
bedtime. 

Cephalalgia. — Headache  should  be  treated  according  to  the  cause. 
Constipation  should  be  removed,  and  iron  should  be  given  when  the 
headache  is  dependent  upon  anaemia.  If  of  malarial  origin,  I  have 
never  hesitated  to  give  quinine  in  large  doses,  and  have  never  yet  ob- 
served its  acting  as  an  oxytocic.  When  purely  of  reflex  origin,  the 
guarana  powder,  the  diffusible  stimulants,  and  the  entire  range  of 
nerve  sedatives  are  indicated.  Unfortunately,  there  are  no  fixed  rules 
by  which,  in  a  given  case,  the  ajjpropriate  remedy  can  be  invariably 
selected. 

Insomnia. — Troublesome  sleeplessness  may  toward  the  end  of  preg- 
nancy reduce  a  woman  to  an  unfavorable  condition  for  encountering 
the  perils  of  childbirth.  The  main  reliance  should  be  placed,  where 
possible,  upon  moderate  exercise,  upon  bromide  of  potassium,  chloral, 
camplior  and  hyoscyamus,  and  codeine.  The  ordinary  forms  of  opium 
should  be  placed  under  the  ban,  on  account  of  the  fatal  facility  with 
which  the  opium  habit  is  acquired.  Even  in  ordering  the  less  ob- 
jectionable hypnotics,  care  should  be  taken  against  their  continued 
employment.  With  proper  caution,  however,  their  occasional  admin- 
istration for  the  purpose  of  breaking  a  morbid  habit  is  to  be  com- 
mended. 


LABOR. 

CHAPTER  VII. 

THE  PHYSIOLOGY  OF  LABOR  AND  ITS  CLINICAL  PHENOMENA. 

Causes  of  labor. — Uterine  contractions. — Action  of  labor-pains  upon  the  uterine 
walls. — Contraction  of  ligaments. — Action  of  abdominal  muscles. — Action  of 
vagina. — The  pain  of  labor. — General  influence  of  labor-pains  upon  the  or- 
ganism.— Precursory  symptoms  of  labor. — First,  second,  and  third  stages  of 
labor. — Duration. — Action  of  the  expellent  forces. 

Under  the  term  labor  are  comprised  all  the  physiological  and  me- 
chanical processes  by  means  of  which  the  extrusion  of  the  ovum  from 
the  maternal  organs  of  generation  is  effected.  As  the  term  implies 
exertion,  its  application  is  restricted  to  the  parturient  efforts  of  vi- 
viparous animals.  The  duration  of  pregnancy  varies  widely  in  the 
different  classes  of  the  animal  kingdom.  The  occurrence  of  normal 
labor  is  coincident  with  the  maturity  of  the  foetus.  This,  in  man,  is 
found  to  correspond  very  nearly  to  the  interval  between  ten  menstrual 
periods. 

Causes  of  Labor. 

Speculation  as  to  the  proximate  causes  of  labor  has  so  far  proved 
profitless.  The  following  particulars  comprise  the  extent  of  our  knowl- 
edge of  the  conditions  which  prepare  the  way  during  pregnancy  for 
the  final  expulsive  efforts  : 

1.  During  the  first  three  months  the  growth  of  the  uterus  is  more 
rapid  than  that  of  the  ovum,  which  is  freely  movable  within  the  uter- 
ine cavity,  except  at  its  placental  attachment.  In  the  fourth  month 
the  reflexa  becomes  so  far  adherent  to  the  chorion  that  it  can  only  be 
separated  by  the  exertion  of  some  slight  degree  of  force,  and  the  am- 
nion is  in  contact  with  the  chorion.  After  the  fourth  month  the 
chorion  and  amnion  are  agglutinated  together,  though  even  at  the  ter- 
mination of  pregnancy  they  may  with  care  be  separated  from  one 
another.  After  the  fifth  month  the  agglutination  of  the  decidua  vera 
and  reflexa  takes  place.  In  the  second  half  of  pregnancy  the  rapid 
development  of  the  ovum  causes  a  corresponding  expansion  of  the 
uterine  cavity,  the  uterine  walls  becoming  thinned,  so  that  by  the  end 
of  gestation  they  do  not  exceed  upon  the  average  two  to  three  lines  in 
thickness.     The  vast  extension  of  the  uterine  surface  is  not,  however. 


124 


LABOR. 


simply  a  consequence  of  over-stretching,  a  fact  shown  by  the  circum- 
stance that  the  uterus  toward  the  close  of  gestation  is  increased  from 
twenty-  to  thirty-fold  in  weight,  and  by  the  histories  of  extra-uterine 
fetations,  in  which,  up  to  a  certain  limit,  the  uterus  enlarges  progress- 
ively, in  spite  of  the  non-presence  of  the  ovum.  The  augmented 
weio'ht  of  the  uterus  is  the  result  of  the  increase  in  length  and  width 
of  the  individual  muscular  fiber-cells,  the  extreme  vascular  develop- 
ment, and  the  abundant  formation  of  connective  tissue.  Ujj  to  the 
sixth  and  a  half  month  there  has  further  been  observed  a  genesis  of 
new  fiber-cells,  especially  upon  the  inner  uterine  surface.  According 
to  Ranvier,  the  smooth  muscular  fibers  become  striated  as  the  end  of 
gestation  is  reached.* 

The  precise  manner  in  which  the  distention  of  the  uterus  is  accom- 
plished has  as  yet  not  been  demonstrated.  A  priori  only  two  possibil- 
ities are  apparently  admissible,  viz.,  either  the  individual  structure 
elements  are  stretched  after  the  manner  of  elastic  bands,  or  a  re- 
arrangement of  the  muscular  elements  t  ikes  place  in  such  wise  that  a 
certain  proportion  of  the  fiber-cells,  instead  of  lying,  as  in  the  begin- 
ning of  pregnancy,  parallel  to  one  another,  gradually,  with  the  ad- 
vance of  gestation,  are  displaced,  so  that  the  ends  only  are  in  juxta- 
position. It  is  probable,  though  not  proved,  that  toward  the  close 
the  thinning  of  the  walls  is  the  result  of  both  conditions.  Bearing 
these  premises  in  mind,  it  becomes  a  disputed  question  as  to  whether 
one  of  the  causes  of  labor  is  not  to  be  found  in  the  reaction  of  the 
uterus,  as  a  hollow  muscular  organ,  from  the  extreme  tension  to  Avhich 
its  fibers  are  ultimately  subjected.  Countenance  to  the  affirmative 
side  is  afforded  by  the  tendency  to  premature  labor  in  hydramnion  and 
multiple  pregnancies,  in  which  a  high  degree  of  tension  is  reached  at 
a  period  considerably  antedating  the  complete  development  of  the 
foetus. 

3.  There  is  a  perceptible  increase  of  irritability  in  the  uterus  from 
the  very  beginning  of  gestation.  Indeed,  the  occurrence  of  spontane- 
ous contractions  has  been  put  forward  by  Braxton  Hicks  as  one  of 
the  distinguishing  signs  of  pregnancy.  This  irritability  is  especially 
marked  at  the  recurrence  of  the  menstrual  epochs  ;  it  is  very  appar- 
ent at  the  beginning  of  pregnancy,  then  diminishes  in  the  middle  pe- 
riod, and  becomes  once  more  a  prominent  feature  in  the  later  months, 
when  spontaneous  painless  contractions  are  ordinary  incidents  of  the 
normal  condition. 

3.  The  researches  of  Friedlander,  Kundrat,  Engelmann,  and  Leo- 
pold have  demonstrated  that  the  decidua  vera  of  pregnancy  is  dis- 
tinguishable into  an  outer,  dense,  membranous  stratum,  composed  of 
large  cells  resembling  pavement  epithelia,  probably  metamorphosed 
cylindrical   cells,   and   an  —  in   appearance  —  underlying   mesh-work, 

*  Vide  Tarxier  et  Chantrkuil,  Traite  de  I'art  des  accouchements,  p.  203. 


THE   PHYSIOLOGY  OF   LABOR. 


125 


formed  from  the  walls  of  the  enlarged  decidual  glands.  It  is  in  this 
spongy  layer  that  the  separation  of  the  decidua  takes  place,  the  fundi 
of  the  glands  persisting,  even  after  the  expulsion  of  the  ovum.  By 
many,  a  fatty  degeneration  of  the  cells  of  the  decidua  has  been 
observed  toward  the  end  of  pregnancy,  but  Leopold,  Dohrn,  and 
I-anghans  have  shown  that  this  is  not  of  constant  occurrence.*  The 
trabeculge  which  inclose  the  spaces  of  the  network  diminish  in  size 


Fig.  61.— The  mucous  membrane  of  the  uterus.  A,  amuion  ;  R,  reflexa  ;  D,  decidua  vera; 
D.  R,  glandular  spaces  of  the  lower  stratum  ;  M,  muscular  structure  of  uterus.  (Engel- 
manu.) 

with  the  advance  of  pregnancy.  Thus,  while  they  measure  at  the 
fourth  month  about  -g^  of  an  inch  in  thickness,  they  become  gradu- 
ally reduced  in  the  subsequent  months  to  -g-^Vo"  ^^  ^^^  inch,  a  change 
which  materially  facilitates  the  peeling  off  of  the  decidual  surface. f 

4.  From  the  fifth  month  onward,  large-sized  cells  make  their 
appearance  in  the  serotina,  especially  in  the  neighborhood  of  thin- 
walled  vessels.  The  largest  of  the  so-called  giant-cells  contain  some- 
times as  many  as  forty  nuclei  Though  a  physiological  product,  they 
resemble  for  the  most  part  the  so-called  specific  cancer-cells  of  the  older 
writers.  They  are  of  special  obstetrical  interest  from  the  fact  observed 
by  Friedltinder,  and  confirmed  by  Leopold, J  that  they  penetrate  the 
uterine  sinuses  from  the  eighth  month,  and  lead  to  coagulation  of  the 
blood,  and  to  the  formation  of  young  connective  tissue,  by  means  of 
which  a  portion  of  the  venous  sinuses  becomes  obliterated  before  labor 
begins.  The  subtraction  of  these  vessels  from  the  circulation  tends  to 
increase  the  amount  of  the  venous  blood  in  the  intervillous  spaces  of 
the  placenta. 

*  Leopold.  Stiidien  iiber  die  Sehleimhaut,  etc.,  Arch.  f.  Gynaek.,  Bd  xi,  p.  49. 

t  Engelmann,  The  Mucous  Membrane  of  the  Uterus,  p.  45. 

i  Op.  cit.,  pp.  492  et  seq.  The  migration  of  the  giant-cells  into  the  maternal 
vessels  described  by  Frankenhaeuser  has  been  questioned  by  Palenko  and  Heinz, 
who  ascribe  the  thrombosis  of  the  vessels  to  proliferation  of  the  endothelial  cells, 
which  subsequently  become  converted  into  giant-cells.  Heinz,  Arch.  f.  Gynaek,  voL 
xxxiii,  p.  417. 


126 


LABOR. 


5.  It  is  proper  to  recall  here  the  fact  that  the  nerve-filaments  of  the 
uterus  are  derived  in  principal  measure  from  the  sympathetic  system. 
The  large  cervical  ganglion,  which  in  pregnancy  measures  about  two 
inches  in  length  by  one  and  a  half  inch  in  breadth,  receives,  however, 
in  addition  to  the  sympathetic  fibers,  filaments  from  the  second,  third, 
and  fourth  sacral  nerves. 

Physiology  has  as  yet  left  unsettled  the  question  as  to  the  main 
channels  of  the  motor  impulses  which  are  conveyed  to  the  uterus  during 
labor.  One  of  my  hospital  patients,  with  paralysis  of  the  lower  ex- 
tremities, retention  of  urine,  and  loss  of  power  over  the  sphincter-ani 
muscle,  had  a  perfectly  natural  though  painless  labor.  The  cause  of 
the  paralysis  was  obscure,  the  patient  subsequently  making  a  complete 
recovery.  Jacquemart  *  reports  a  similar  case,  in  which  the  paralysis 
was  due  to  partial  compression  of  the  cord  at  the  level  of  the  first 
dorsal  vertebra.  On  the  other  hand,  Schlesinger  f  has  shown  that  the 
sympathetic  is  not  the  only  motor  nerve,  as  reflex  movements  of  the 
uterus  follow  stimulation  of  the  organ  when  all  the  branches  of  the 
aortic  plexus  have  been  carefully  divided. 

A  motor  center  for  uterine  contractions  has  been  proved  to  exist  in 
the  medulla  oblongata.  This  center  is  excited  directly  to  action  by 
anaemic  conditions,  and  by  the  presence  of  carbonic  acid  in  the  blood 
conveyed  to  it.  Vivid  mental  emotions  may  either  awaken  or  suspend 
uterine  contractility. 

Reflex  movements  of  the  uterus  may  be  provoked  by  stimulating 
the  central  end  of  any  of  the  spinal  nerves — a  fact  which  serves  to  ex- 
plain the  consensus  long  recognized  as  existing  between  the  breasts 
and  the  organs  of  generation.  When  the  spinal  cord  is  divided  below 
the  medulla  oblongata,  this  phenomenon  is  no  longer  observed.  Direct 
stimuli  to  the  uterus,  however,  determine  contractions  independently 
of  the  medulla  oblongata,  the  spinal  cord  then  acting  as  a  reflex  center. 
The  presence  of  asphyxiated  blood  in  the  arterial  trunks  acts  as  a 
physiological  stimulus  to  labor.  |  By  the  separation  of  the  decidua 
from  its  organic  connection  with  the  uterus,  the  ovum  acts  as  a 
foreign  body,  and,  as  is  well  known,  speedily  awakens  uterine  move- 
ments. Finally,  Kehrer*  has  shown  that,  when  a  cornu  is  removed 
from  the  uterus  during  labor,  rhythmic  contractions  of  the  mus- 
cular fibers  will  continue  from  a  half-hour  to  an  hour  after  separa- 
tion, provided  only  the  tissues  be  kept  moist  and  at  a  suitable  tem- 
perature. || 

*  Tarnier  et  Chantreuil,  Traite  de  I'art  des  accouchements,  p.  229. 
t  Ober  und  Schlesinger,  Strieker's  Wiener  med.  .Jahrbuch.  1872. 

I  Vide  Schlesinger,  Strieker's  Wiener  med.  Jahrbuch,  1873. 

*  Kehrer,  Beitrage  zur  vergleichende  und  experimentellen  Geburtskunde,  2tes 
Heft,  p.  48. 

H  CoHNSTEiN  (Zur  Innervation  der  Gebarmutter,  Arch.  f.  Gynaek.,  vol.  xviii. 


THE   PHYSIOLOGY  OF  LABOR. 


12Y 


The  following  theory  of  the  causes  of  labor  is  offered,  not  because 
of  its  completeness,  but  merely  as  a  means  of  grouping  the  foregoing 
facts  together  in  the  order  of  their  relative  importance.  The  advance 
of  pregnancy  is  associated  with  increase  in  the  irritability  of  the  uterus, 
a  property  most  pronounced  at  the  recurrence  of  the  menstrual  epochs. 
By  thinning  of  the  partitions  between  the  glandular  structures  the 
way  is  prepared,  as  the  time  for  labor  approaches,  for  the  easy  separa- 
tion of  the  dense  inner  stratum  of  the  decidua.  The  ready  response 
of  the  uterus  to  stimuli  reflected  from  the  peripheral  extremities  of 
the  spinal  nerves,  to  direct  local  irritation,  and  to  the  presence  of  blood 
surcharged  with  carbonic  acid  in  the  uterine  vessels,  explains  the  fre- 
quency of  painless  contractions  for  days,  or  even  weeks,  in  some  cases, 
previous  to  labor.  To  these  means  of  exciting  uterine  motility  there 
should  be  added,  in  all  probability,  the  reaction  of  the  uterine  muscle, 
from  the  tension  to  which  it  is  subjected  by  the  growth  of  the  ovum, 
and  to  circulatory  disturbances  in  the  cerebral  centers  sometimes 
effected  by  vivid  emotions.  Frequently  repeated  uterine  contractions, 
without  partial  separation  of  the  decidua,  are  hardly  comprehensible 
after  the  decidua  vera  and  reflexa  are  brought  into  close  contact  with 
one  another.  Such  a  physiological  separation  would  of  necessity, 
when  of  sufficient  extent,  by  converting  the  ovum  into  a  foreign  body, 
furnish  an  active  cause  for  the  advent  of  labor,  in  the  same  way  that 
labor  is  prematurely  excited  by  a  similar  separation  when  artificially 
induced.  Thus,  by  the  time  the  development  of  the  foetus  is  com- 
pleted, all  things  are  in  train  for  its  expulsion.  When  other  causes 
do  not  early  operate  as  determining  forces,  the  increase  of  uterine 
irritability  at  the  recurrence  of  the  menstrual  epochs  probably  accounts 
for  the  ordinary  coincidence  of  labor  with  the  tenth  catamenial  date. 

Physiological  Phenomena  of  Labor. 

The  Uterine  Contractions. — The  uterine  contractions  are  entirely 
independent  of  volition.  As  in  other  organs  composed  of  smooth 
muscular  fibers,  each  contraction  at  the  beginning  is  slow  and  weak ; 
gradually  it  reaches  the  point  of  greatest  intensity ;  the  acme  con- 
tinues for  a  brief  period,  and  then,  finally,  is  followed  by  complete 
relaxation.  Each  complete  excursion  is  termed  a  labor-pain.  Peri- 
staltic movements  have  been  observed  in  animals  with  two-horned 
uteri.  A  similar  action,  proceeding  from  the  fundus  to  the  cervix, 
has  been  sometimes  assumed  for  the  human  subject.  The  peristaltic 
wave,  however,  if  indeed  it  exists,  extends  so  rapidly  that  it  is  best 
to  consider  the  uterus  as  a  hollow  muscle,  which  contracts  simulta- 

p.  394),  from  his  own  experiments  and  those  of  others,  concludes  that  the  determin- 
ing cause  of  the  uterine  contractions  is  contained  in  the  intra-muscular  ganglionic 
cells :  that  the  central  nerve-organs  regulate  the  uterine  activity,  and  that  the  sym- 
pathetic acts  simply  as  a  vaso-motor  nerve. 


128 


LABOR. 


neously  in  all  its  parts.  As  labor  advances,  an  increase  in  the  length 
and  the  force  of  the  contractions  is  developed.  The  stronger  the 
pains,  the  shorter  is  the  interval  between  them.  The  average  normal 
duration  of  a  labor-pain  is  about  one  minute. 

The  Action  of  Labor-Pains  upon  the  Uterine  Walls.— During  the 
intervals  between  the  pains,  it  is  well  known  that  the  uterus  possesses 


Fig.  63.— Transverse  section,  dotted  line 
representingr  shape  of  uterus  during 
a  pain.    (Lahs.) 


Fig.  fi3.— Longitudinal  section,  dotted 
line  representing  elevation  of  fun- 
dus during  a  pain.    (Lahs.) 


an  ovoid  shape,  and  is  flattened  antero-posteriorly  by  the  pressure  of 
the  abdominal  walls.  During  the  pains,  however,  the  uterus,  as  it 
closes  upon  the  fluid  contents  of  the  ovum,  assumes  a  more  nearly 
globular  outline.  As  a  consequence,  the  transverse  diameter  is  dimin- 
ished, and  the  antero-posterior  increased  in  corresponding  proportion. 
By  this  change,  the  uterus,  which  had  previously  rested  by  its  poste- 
rior surface  upon  the  spinal  column,  rises  upward  so  that  its  fundus 
produces  a  bulging  of  the  anterior  abdominal  walls. 

Owing  to  the  loose  connection  of  the  muscular  strata  with  the  peri- 
tongeum  in  the  lower  uterine  segment,  the  walls  of  the  latter  offer  less 
resistance  to  the  pressure  of  the  ovum,  and  thus  are  stretched  downward 
during  each  pain.  While,  in  contractions  of  the  uterus,  the  lower  seg- 
ment is  thinned,  the  diminished  bulk  of  the  contracted  organ  leads  to 
an  increase  in  the  thickness  of  the  walls  of  the  body  and  fundus.* 

The  Contractions  of  the  Uterine  Ligaments. — Structurally  the  mus- 
cular fibers  of  the  round  and  broad  ligaments  are  in  direct  continuity 
with  the  external  muscular  layer  of  the  uterus.  As  would  be  antici- 
pated, they  contract  simultaneously  with  that  organ.  In  contracting, 
they  help  to  fix  the  uterus  at  the  pelvic  brim. 

*  For  most  of  the  following  deductions  the  writer  is  indebted  to  Dr.  Lahs'9 
ingenious  work  entitled  Die  Theorie  der  Geburt.  For  modifications  in  details  in 
the  present  edition,  vide  inter  alios  Werth,  Die  Physiologie  der  Geburt,  MCller's 
Handbuch  der  Geburtshiilfe,  vol,  i,  p.  330. 


THE   PHYSIOLOGY   OF   LABOR. 


129 


v^ / 

O 


Fig.     64.  —  Diagram 
changes    in    the 


representing 
thicl^ness    fif 


uterine  walls  during  labor.    (Lahs.^ 


the 
the 


The  Action  of  the  Abdominal  Muscles.— The  contraction  of  the 
abdominal  walls  is  a  powerful  auxiliary  to  the  expulsive  action  of  the 
uterus.  At  the  beginning  of  labor  the  contractions  are  voluntary, 
but  as  labor  advances  they  become  more  and  more  reflex  in  charac- 
ter, until,  in  many  women,  the  dis- 
position to  press  during  each  pain  as- 
sumes the  form  of  an  uncontrollable 
impulse.  The  mechanism  by  which 
these  auxiliary  forces  are  called  into 
play  is  as  follows :  As,  toward  the 
acme  of  the  pain,  the  fundus  uteri  is 
elevated  and  lifts  up  the  abdominal 
walls,  the  woman  takes  a  deep  ins^jira- 
tion,  the  glottis  closes,  and  the  dia- 
phragm contracts.  The  latter  pushes 
the  intestines  downward,  and  thus 
aids  in  raising  the  uterus  to  a  position 
nearly  perpendicular  to  the  pelvic 
brim.  All  the  expiratory  muscles  then 
enter  into  active  contraction.  Mean- 
time, the  laboring  woman  secures  fixa- 
tion of  the  trunk  by  finding  points  of  support  for  the  upper  and  lower 
extremities.  By  these  means  the  capacity  of  the  abdominal  cavity  is 
greatly  diminished,  and  the  uterus  is  compressed  not  only  by  the  ad- 
jacent muscular  coverings,  but  by  the  entire  mass  of  inclosed  viscera. 
The  effect  is  twofold  : 

1.  There  results  an  augmentation  of  the  intra-uterine  pressure. 

2.  A  portion  of  the  contents  of  the  large  vessels  of  the  trunk  is 
forced  to  the  extremities.  To  this  cause  is  attributable  the  flushed, 
congested  appearance  of  the  face  during  labor-pains.  As  the  intra- 
abdominal pressure  is  not  brought  to  bear  upon  the  organs  within  the 
pelvic  cavity,  hypersemia  of  the  vagina  and  the  contiguous  tissues 
follows.  As  a  consequence,  the  channel  through  which  the  head  has 
to  pass,  as  labor  advances,  becomes  infiltrated  with  serum,  and  offers 
less  resistance  to  the  presenting  part.  At  the  same  time  the  glandu- 
lar structures  are  excited  to  increased  action,  and  the  lining  mucous 
membrane  becomes  lubricated  by  the  secretion  which  is  freely  poured 
out. 

The  Influence  of  the  Vagina  in  Parturition.— As  the  head  advances 
through  the  cervix,  the  vagina  at  first  opposes  an  obstacle  to  its  fur- 
ther progress.  After,  however,  the  largest  circumference  of  the  child 
has  passed  through  the  genital  canal,  the  contractions  of  the  vagina 
aid  somewhat  in  the  expulsion  of  the  after-coming  extremities  and  of 
the  placenta. 

The  Pains  of  Labor.— The  painful  sensations  which  are  the  accom- 


130 


LABOR. 


paniment  of  the  uterine  contractions  begin  in  the  lower  uterine  seg- 
ment. They  are  at  first  especially  felt  over  the  sacrum,  Avhence  they 
radiate  to  the  rectum  and  the  bladder,  across  the  abdomen,  and  down 
the  thighs.  In  the  beginning  of  labor  the  sensations  are  dull,  and  of 
a  bearing-down  character.  As  labor  advances,  however,  the  pains 
increase  in  acuteness,  and  in  many  persons  reach  an  unendurable  de- 
gree of  severity.  They  are  mainly  induced  through  the  compression 
of  the  uterine  nerves  by  the  contractions  of  the  muscular  fibers.  They 
are  probably  likewise  in  part  the  result,  as  Werth  suggests,  of  hyperaemia 
of  the  lower  extremity  of  the  sjiinul  cord  and  of  its  envelopes.  The 
severity  of  the  pains  is  proportioned  to  the  resistance  to  be  overcome. 
At  first,  as  has  been  stated,  confined  to  the  lower  segment  of  the 
uterus,  the  pains  subsequently  invade  the  body  and  the  fundus.  The 
sufferings  of  the  female  increase  with  the  mechanical  distention  of 
the  cervix,  especially  with  that  of  the  external  orifice,  and  finally 
reach  the  point  of  supreme  agony  as  the  head  jjasses  through  the 
vagina  and  vulva,  which  are  abundantly  supplied  witli  sensitive  spinal 
nerves. 

The  pains  are  often  greater  in  very  young  or  in  elderly  primipar* 
than  in  women  at  the  prime  of  physical  life.  Though  labor  is  rarely 
absolutely  painless,  where  the  first  stage  is  slow  and  the  resistance  of 
the  soft  parts  slight  the  suffering  may  become  comparatively  insignifi- 
cant. 

Influence  of  the  Pains  upon  the  Organism. — During  each  pain  the 
arterial  pressure  is  increased  ;  the  rrecpiency  of  the  pulse  rises  until 
the  acme  is  reached,  when  it  slowly  declines  to  the  normal  jioint ;  the 
respirations  are  slowed  during  the  pains,  owing  to  the  contraction  of 
the  abdominal  walls,  but  are  more  rapid  in  the  pauses  as  a  consequence 
of  the  general  muscular  exertion  ;  the  temperature  rises  progressively 
during  labor,  but,  as  a  rule,  within  narrow  limits;  and  tlie  urinary  ex- 
cretion, in  consequence  of  the  increased  arterial  pressure,  is  augmented.* 

The  Clixical  Course  of  Labor. 

Precursory  S3nnptoms.— About  the  thirty-ninth  week  of  pregnancy 
it  is  usual  for  the  entire  uterus  to  sink  somewhat  downward  into  the 
pelvis,  while  the  fundus  falls  forward.  This  change  of  position  is 
followed  by  considerable  relief  to  the  respiration,  and  to  previously 
existing  gastric  disturbances.  At  the  same  time  there  is  experienced 
an  increased  difficulty  in  locomotion ;  the  oedema  of  the  lower  extremi- 
ties is  aggravated ;  the  intra-pelvic  pressure  causes  a  frequent  desire 
to  urinate,  and  predisposes  to  the  development  of  haemorrhoids,  espe- 
cially where,  as  is  the  rule  in  primiparae,  the  head  likewise  descends 
deep  into  the  pelvic  cavity.      Indeed,  in  primiparse  the  changes  of 

*  Naegele,  Lehrbuch  der  Geb.,  p.  163.  . 


THE   PHYSIOLOGY   OF  LABOR.  131 

position  are  more  pronounced  than  in  women  who  have  passed  throucrh 
re2)eated  pregnancies.  As  gestation  drjiws  to  a  close,  a  copious  glairy 
secretion  is  poured  out  from  the  cervix,  the  vagina  relaxes,  the  labia 
majora  become  swollen,  and  the  vulva  gapes  open.  For  a  variable 
period  preceding  the  advent  of  labor,  painless  contractions  occur  at 
irregular  intervals.  These  so-called  dolores  presagientes  are  the  ordi- 
nary prelude  to  labor  in  multipar^e,  thougTi~HTeyare^teTi  inappreciable 
in  primiparjB.  They  very  commonly  begin  in  the  evening  hours  and 
continue  till  toward  the  middle  of  the  night.  Very  often  they  are  as- 
sociated with  a  dragging  sensation  between  the  sacrum  and  symphysis 
and  a  feeling  of  tension  in  the  abdominal  region.  Sometimes  they 
expand  the  os  internum  to  a  considerable  extent,  but  never  in  such  a 
way  that  any  portion  of  the  cervical  canal  contributes  to  the  enlarge- 
ment of  the  uterine  cavity. 

Actual  labor  has  been  divided,  as  a  matter  of  clinical  convenience, 
into  three  stages,  as  follows  : 

First  stage,  or  stage  of  dilatation  of  the  cervical  canal. 

Second  stage,  or  the  stage  of  expulsion,  comprising  the  laeriod  from 
the  dilatation  of  the  cervix  to  the  expulsion  of  the  child. 

Third  stage,  or  stage  of  the  placental  delivery. 

1.  The  First  Stage — Dilatation  of  the  Cervix. — The  advent  of  true 
labor  is  characterized  by  painful  contractions,  which  render  the  patient 
restless,  and  dispose  her  either  to  bend  forward  with  clinched  hands, 
or  to  seek  some  firm  support  for  the  sacrum  to  ease  her  sufferings. 
Usually,  in  the  beginning  of  labor,  women  prefer  the  sitting  posture, 
which  enables  them  to  press  with  the  forearm  against  the  sacrum  dur- 
ing the  pains.  The  pain  of  labor  begins  with  the  dilatation  of  the 
internal  os.  In  true  labor  the  dilatation  progresses  gradually.  As  the 
OS  internum  opens,  the  contractions  cause  the  membranes  to  descend 
and  press  upon  the  cervical  canal.  With  the  advance  of  labor  the 
pains  increase  in  intensity  and  frequency.  During  their  persistence 
the  external  os  is  put  upon  the  stretch,  so  that  the  border  becomes 
thin  and  sharply  defined.*  As  the  pain  subsides,  the  os  relaxes  and 
the  membranes  retreat.  Each  new  pain  increases  the  dilatation,  and 
forces  the  membranes  somewhat  deeper.  The  softening,  the  relaxa- 
tion, and  the  hypersecretion  of  the  soft  parts  become  more  and  more 
decided.  As  the  borders  of  the  os  yield  to  pressure,  lacerations  occur, 
which  tinge  the  mucous  discharges  with  blood.  When  the  dilatation 
has  reached  a  certain  limit  (usually  by  the  time  the  diameter  of  the 
external  os  is  three  to  three  and  a  half  inches),  the  protruding  mem- 
branes remain  tense  in  the  intervals  between  the  pains,  and  are  then 
ready  for  rupture.  After  rupture,  which  usually  occurs  spontaneously, 
the  water  in  front  of  the  child's  head  escapes,  though  the  greater  part 

*  In  multiparjc  this  resistance  of  the  external  os  may  be  entirely  lacking. 


132 


LABOR. 


of  the  amniotic  fluid  is  retained  within  the  uteru^  by  the  valve-like 
pressure  of  the  presenting  part..  After  a  short  pause  the  head  descends 
into  the  cervix,  the  walls  of  which  are  stretched  to  the  pelvic  borders, 


liq.  amnios. 


Fig.  65. — Section  through  a  frozen  corpse.    Stage  of  expulsion.    (Braune.) 

and  finally  become  so  dilated  that  cervix  and  vagina  form  one  con- 
tinuous canal. 

In  case  the  presenting  part  does  not  thoroughly  tampon  the  lower 
segment  of  the  uterus,  a  more  or  less  complete  escape  of  the  entire 
amniotic  fluid  may  follow  the  rupture  of  the  membranes.  As  a  rule, 
the  tear  in  the  membranes  takes  place  in  the  most  dependent  point 
of  the  convex  portion  which  constitutes  the  bag  of  waters  in  the  cer- 
vical canal.  Sometimes,  however,  the  rupture  takes  place  above  the 
cervix,  where  there  can  be  a  gradual  escape  of  fluid  in  spite  of  the  per- 
sistence of  the  bag  of  waters. 

If  the  membranes  rupture  before  the  dilatation  of  the  cervix  is 
complete,  the  head  descends  and  acts  as  a  dilating  wedge.     In  rare 


THE   PHYSIOLOGY   OF   LABOR. 


133 


cases  the  rupture  of  the  membranes,  if  left  to  nature,  does  not  occur 
and  the  ovum  may  descend  in  its  integrity  to  the  vulva.  In  such  in- 
stances the  membranes  sometimes  rupture  in  the  neighborhood  of  the 


! I  IT /'■''''  ^ 


placent 


orif.  tub 


vagina, 
rectum. 


ureth 


Fig.  66.— The  uterus  and  parturient  canal.    Ftetus' removed.    (Braune.) 

child's  neck,  and  the  head  is  born  covered  with  the  so-called  "caul," 
i.  e.,  with  the  detached  portion  of  the  membranes,  which  old  nurses 
regard  as  significant  of  good  luck.  In  still  rarer  cases,  where  the  fretus 
is  small  and  the  amount  of  amniotic  fluid  limited,  the  entire  ovum 
may  be  expelled  without  rupture  of  its  coverings. 

2.  The  Second  Stage— The  Stage  of  Expulsion.— After  the  short 
pause  which  follow^s  the  rapture  of  the  membranes,  the  pains  become 
stronger  and  more  frequent,  and  are  now  powerfully  re-enforced  by  the 
involuntary  contractions  of  the  abdominal  muscles,  which,  though  pre- 
viously not  entirely  inactive,  have  played  only  a  sixbordinate  part.  With 
each  pain  the  head  now  makes  perceptible  progress,  retreating,  however, 


j^y^  LABOR. 

as  the  Tjains  decline.  After  the  head  has  passed  the  pelvic  outlet,  and  is 
covered  only  by  the  soft  parts,  the  perinaeum  bulges  outward,  the  labia 
ffape,  and  a  portion  of  the  head  makes  its  appearance  at  the  vulva. 
As  within  the  pelvic  canal,  with  each  pain  the  head  advances,  and  puts 
the  perinreum  upon  the  stretch,  receding  somewhat  in  turn  as  the 
pains  subside.  The  pressure  upon  the  rectum  leads  to  the  evacuation 
of  fecal  contents.  Finally,  the  thinning  of  the  perineum  reaches  a 
point  at  which  the  sutures  can  be  readily  felt  through  its  structure  ; 
the  recession  of  the  head  ceases ;  the  anus  assumes  an  oval  shape ;  the 
orifice  of  the  vulva  looks  forward  and  upward  ;  the  urethra  is  pushed 
against  the  symphysis  pubis ;  while,  as  the  circumference  of  the  head 
in  the  neighborhood  of  the  parietal  bosses  engages  in  the  vulva,  the 
labia  and  frenulum  form  a  thin  circular  band,  through  which,  during 
a  pain  or  the  contraction  of  the  abdominal  walls,  the  head  makes  its 
way,  usually  leaving  behind  moderate  lacerations  of  the  fraenulum  or 
anterior  portion  of  the  perinjeum.  The  same,  or  the  succeeding  pain, 
leads  to  the  expulsion  of  the  trunk.  The  birth  of  the  child  is  fol- 
lowed by  the  outpouring  of  the  amniotic  fluid,  which,  as  a  rule,  escapes 
colored  with  blood  from  the  site  of  the  wholly  or  partially  detached 
placenta. 

3.  The  Third  Stage— The  Stage  of  the  Placenta.— The  placental 
period  embraces  tlie  time  from  the  birtii  of  tlic  child  to  the  delivery 
of  the  placenta  and  membranes. 

After  the  birtli  of  the  child,  the  recession  of  the  blood  from  the 
brain,  which  follows  the  diminution  of  the  intra-abdominal  pressure, 
often  produces  a  sense  of  faintness,  and  sometimes  temporary  syncope. 
The  rapid  evacuation  of  the  uterus  is  at  times,  too,  succeeded  by  a 
chill,  which,  however,  does  not  betoken  the  onset  of  fever,  but  is  the 
result  of  vaso-motor  disturbance,  and  the  loss,  through  the  expulsion 
of  the  child,  of  a  source  of  heat-supply.  Most  women,  however,  ex- 
perience a  restful  feeling  of  comfort  and  repose.  This  sense  of  qui- 
etude lasts  anywhere  from  a  few  minutes  to  a  quarter  of  an  hour,  when 
the  contractions  return,  which  detach  the  placenta,  and  force  it  into 
the  vagina.  The  separation  of  the  placenta  takes  place  in  the  meshy, 
lamellated  layer  which  is  formed  in  th,e  serotina  by  the  thinned,  elon- 
gated walls  of  the  gland-tubules,  the  dense  cell-layer  of  the  maternal 
portion  remaining  adherent  to  the  placenta.  As  the  maternal  vessels 
are  necessarily  torn  across,  some  haemorrhage  follows  the  detachment. 
The  haemorrhage  is,  however,  speedily  arrested  by  the  contractions  of 
the  uterus,  which  both  compress  the  vessels  and  furnish  the  conditions 
favorable  to  the  formation  of  fibrinous  clots  in  their  distal  extremities. 
When  the  mechanism  of  expulsion  is  left  to  nature,  the  placenta  de- 
scends by  its  edge  into  the  vagina,  while  premature  tractions  upon  the 
cord  cause  it  to  present  by  its  fetal  surface  at  the  cervical  orifice. 
When  once  in  the  vagina,  the  expulsion  is  completed  by  the  action  of 


THE   PHYSIOLOGY  OF   LABOR.  ^^^ 

the  abdominal  muscles,  sustained  by  the  retraction  of  the  muscles  which 
form  the  floor  of  the  pelvis. 

According  to  Gassner,*  after  confinement  the  female  experiences 
as  a  consequence  of  the  expulsion  of  the  ovum,  of  the  exhalations  from 
the  lungs  and  skin,  from  the  discharge  of  excrements,  and  from  hsem- 
orrhage,  a  loss  of  weight  equivalent  to  one  ninth  of  that  of  the  entire 
body. 

Duration  of  Labor. — Spiegelberg  found,  in  506  labors,  the  average 
for  primipara?  was  KJiours,  for  multipara  12  hours.  In  primipar* 
past  the  thirtieth  year  Hecker  found  the  average  21-1  hours,  while 
Ahlfeld,  in  82  women  over  thirty-two  years  of  age,  obtained  an  average 
of  27.6  hours. f 

In  ordinary  normal  labor  the  second  stage  lasts  about  two  hours  in 
primiparfe,  and  about'  half  as  long  in  multiparae,  though  in  the  latter 
the  resistance  is  frequently  so  slight  that  a  few  pains  suffice  to  com- 
plete the  delivery. 

According  to  Kleinwachter,J  the  time  at  which  labor-pains  begin 
occurs  most  frequently  between  ten  and  twelve  o'clock  in  the  evening. 
Spiegelberg  *  states  that  the  maximum  frequency  of  births  takes  place 
between  twelve  and  three  o'clock  in  the  morning. 

The  Actiox  of  the  Expellext  Forces. 

Having  considered  separately  the  action  of  the  uterus,  the  uterine 
appendages,  and  the  abdominal  muscles  during  labor,  there  remams 
for  us  to  combine  these  factors  together,  and  to  show  in  what  manner 
they  contribute  to  the  end  of  all  parturient  effort,  viz.,  the  expulsion 
of  the  ovum. 

In  the  first  place,  the  contractions  of  the  uterus  are  intermittent. 
"When  they  lose  their  rhythmical  quality  and  become  continuous,  they 
cease  to  belong  to  the  domain  of  physiology.  It  is  only  during  the 
act  of  contraction  that  work  is  performed.  Whenever  the  alternating 
relaxation  ceases,  and  the  uterus  passes  into  a  condition  of  tonic  con- 
traction, no  work  is  accomplished,  and  the  pains  are  ineffective. 

The  uterus  is  a  hollow  muscle,  which  during  a  pain  closes  down 
upon  its  contents.  If  all  parts  of  the  uterine  walls  offered  an  equal 
resistance,  the  force  of  the  contractions  would  be  expended  upon  the 
periphery  of  the  ovum,  and,  as  the  contents  of  the  latter  are  practically 
incompressible,  the  effort  would  be  resultless.  If,  however,  the  walls 
were  so  constructed  that  the  distensibility  varied  in  different  regions, 

*  Gassner,  Ueber  d.  Veranderungen  des  Korpergewichtes  b.  Schwang.,  Gebar. 
und  Wochner,  Monatsschr.  f.  Geburtsk.,  xix,  p.  18. 

f  Spiegelberg,  Lehrbuch,  pp.  134,  135. 

i  Kleinwachter,  Die  Zeit  des  Geburtsbeginnes,  Ztschr.  f.  Geburtsh.,  Bd.  i, 
p.  230. 

*  Spiegelberg,  Lehrbuch,  etc.,  p.  135. 


136  ^^20^- 

the  peripheral  compression  exerted  during  a  pain  would  be  followed  by 
a  bulging  at  the  points  of  least  resistance,  provided  the  tissue  acted 
upon  possessed  the  property  of  elasticity.  Now  it  is  an  anatomical 
fact,  that  during  a  labor-pain  a  stretching  of  the  fundus  and  of  the 
lower  uterine  segment  actually  takes  place.  Indeed,  after  continued 
labor  we  often  find  the  intermediate  portion  of  the  uterus  two  to 
three  times  as  thick  as  the  lower  segment.  As  a  result  of  these 
conditions,  concentric  pressure  of  the  fluid  contents  of  the  ovum  is 
followed  by  an  increase  in  the  longitudinal  diameter  of  the  uterus. 
While  the  convexity  of  the  fundus  is  unquestionably  increased  during 
a  pain,  the  effect  of  the  latter  is  chiefly  manifested  in  the  distention  of 
the  lower  segment.  Various  causes  combine  to  produce  this  result. 
Thus,  the  muscular  structures  of  the  lower  segment  are  loosely  as- 
sociated together,  and  are  easily  separable  from  the  peritonseum.  They 
therefore  offer  a  less  resistance  than  that  afforded  by  the  close  inter- 
lacement of  both  circular  and  longitudinal  fibers  which  prevails  in  the 
fundal  and  upper  uterine  zones.  Then,  too,  as  was  pointed  out  by 
Lahs,*  the  lower  segment  sustains,  in  the  ordinary  positions  assumed 
by  the  female,  the  entire  weiglit  of  the  superimposed  ovum  with  its 
fluid  and  solid  contents ;  and,  finally,  the  pressure  transmitted  from 
the  abdominal  muscles  takes  a  direction  from  above  downward. 

In  1876  Bandl  f  called  attention  to  the  thinned  condition  of  the 
lower  uterine  segment,  extending  from  what  had  been  previously  re- 
garded as  the  OS  internum  from  four  to  six  inches  upward,  and  ter- 
minating abruptly  in  a  muscular  ridge  upon  the  inner  surface.  This 
ridge  he  regarded  as  the  upper  limit  of  the  cervical  canal,  which  had 
been  opened  up  by  the  growth  of  the  ovum.  Lahs  J  however,  places 
this  ring  at  the  level  of  the  pelvic  brim.  Above  the  pelvic  brim,  he 
says,  the  convexity  of  the  uterus  is  nearly  uniform,  while  the  portion 
of  the  uterus  below  forms,  as  it  were,  a  segment  of  a  sphere  with  a 
short  radius  attached  to  tlie  abdominal  division.  In  this  way,  upon 
longitudinal  section,  a  projection  of  the  wall  toward  the  uterine  cavity 
is  observable  at  the  pelvic  brim  where  the  two  segments  meet.  He 
therefore  proposes  that  the  ridge  thus  produced  be  called  the  "  pelvic- 
brim  stricture."  My  own  observations,  which  correspond  to  those  of 
Schroeder,  show  that  in  many  instances  this  ridge  is  but  slightly  indi- 
cated before  the  beginning  of  labor.  During  and  as  a  consequence  of 
the  labor-pains,  the  ridge  becomes  well  marked,  and  clearly  defines  the 
limits  between  the  thinned,  stretched  lower  portion  and  the  thickened, 
retracted  upper  portion  of  the  uterus.  Both  from  a  physiological  and 
a  pathological  point  of  view  this  limiting  ring  possesses  great  import- 

*  Lahs,  Die  Theorie  der  Geburt.  p.  116. 

\  Bandl,  Ueber  das  Verhalten  des  Uterus  und  Cervix  in  der  Schwangerschaft 
uud  wahrend  der  Geburt. 

I  Lahs,  Was  heisst  Unteres  Uterinsegment,  Arch.  f.  Gynaek.,  vol.  xxiii,  p.  215. 


THE   PHYSIOLOGY   OF   LABOR. 


137 


ance.  It  is  desirable,  therefore,  that  it  receive  a  designation  definitive 
of  its  character.  The  term  "  ring  of  Bandl,"  which  has  received  some 
currency,  is  objectionable,  because  that  term  has  already  beconue  asso- 
ciated with  Bandl's  views  as  to  the  true  position  of  the  internal  os. 
The  "  pelvic-brim  stricture  "  of  Lalis  has  an  awkward  sound  in  Eng- 
lish, and  expresses  a  theory  not  yet  absolutely  established.  Ebell  pro- 
posed the  name  "  mechanical  or  clinical  os,"  but  it  requires  a  complete 
familiarity  with  the  discussion  which  the  subject  has  occasioned  not  to 
confound  the  structure  with  the  orifices  of  the  cervical  canal.  My  own 
choice  would  be  to  term  it  the 
"  retraction  ring,"  as  indicative 
of  what  I  believe  to  be  its  ori- 
gin. As,  however,  Schroeder 
has  already  introduced  the  term 
"  contraction  ring,"  and  as  that 
term  has  become  somewhat  fa- 
miliar, I  have  thought  it  best 
to  accept  that  designation  in 
these  pages  in  spite  of  criti- 
cisms which  have  been  made  as 
regards  its  propriety. 

So  far,  for  the  sake  of  sim- 
plicity, we  have  regarded  the 
uterus  as  a  closed  sac,  possess- 
ing walls  of  unequal  thickness. 
In  reality  the  lower  segment  ter- 
minates in  an  opening,  the  canal 
of  the  cervix,  which,  though  at 
the  beginning  gf  labor  of  small 
size,  and  offering  considerable 
resistance  to  the  pressure  of  the 
ovum,  is  capable  of  sufficient 
distention  to  permit  the  exit  of 
the  foetus. 

The  dilatation  of  the  cervix  is  partly  mechanical,  and  partly  the 
effect  of  certain  organic  changes  which  have  already  received  cursory 
mention. 

The  mechanical  dilatation  is  the  result  of— 1.  The  pressure  of  the 
ovum  upon  the  lower  uterine  segment,  which  forces  open  the  os  inter- 
num, and  unfolds  the  cervix  from  above  downward. 

2.  The  retraction  of  the  uterus  is  an  important  property,  which 
requires  brief  description.  While  each  contraction  of  the  uterus  is 
followed  by  relaxation  and  a  period  of  repose,  a  gradual  change  is  con- 
tinually going  on  in  the  length  and  arrangement  of  the  muscular 
fibers.     In  the  thinned  lower  segment  the  fibers  are  stretched,  and 


FiQ.  67.— Longitudinal  section  tlirougli  walls  of 
uterus  in  eighth  month  of  prt  gnancy  ( Bandl). 
a,  contraction  ring,  or  ring  of  Bandl ;  6,  os  in- 
ternum ;  cl,  OS  externum. 


138 


LABOR. 


separated  from  one  another.  lu  the  upper  portion,  on  the  contrary, 
they  shorten,  and  change  their  position  in  such  a  way  that  those  which 
previo^isly  had  only  their  extremities  in  contact  assume  a  more  nearly 
parallel  arrangement.  The  walls,  therefore,  in  the  upper  zones  thicken 
and  shorten,  especially  in  the  longitudinal  direction.  The  limit  be- 
tween the  thinned  lower  segment  and  the  upper  thickened  zones  is 
marked,  as  we  have  seen,  by  a  distinct  ridge  termed  by  Schroeder  the 
contraction  ring.  It  is  to  the  changes  in  the  uterus  which  take  place 
above  the  contraction  ring  that  the  term  retraction  is  apijlicable.  As 
the  retraction  is  progressive,  it  leads  to  a  gradual  withdrawal  upward 
of  the  uterine  walls,  in  consequence  of  which  the  lower  segment  is  not 
only  put  upon  the  stretch  during  the  pains,  but  toward  the  end  of  the 
period  of  dilatation  is  subjected  to  a  greater  or  less  degree  of  perma- 
nent tension.  Then,  too,  as  the  contraction  ring  moves  upward,  a 
phenomenon  observable  where  the  descent  of  the  head  is  hindered,  the 
longitudinal  fibers  of  the  lower  segment,  by  reason  of  their  insertion  in 
part  at  least  into  the  vaginal  portion,  exert  a  direct  influence  in  dilat- 
ing the  cervical  canal. 

3.  When  the  abdominal  muscles  contract,  the  uterus  is  pressed  down- 
ward into  the  pelvic  cavity.  The  descent  is,  however,  limited  by  the 
attachment  of  the  uterine  ligaments  and  the  adjacent  organs.  But  the 
resistance  afforded  by  the  uterine  attachments  exercises  a  peripheral 
traction  upon  the  cervix,  and  thus  tends  to  draw  its  walls  asunder. 

The  normal  dilatation  of  the  cervix  is,  however,  by  no  means  a 
matter  of  pure  mechanical  distention.  If  the  canal  which  forms  the 
communication  between  the  vagina  and  the  uterus  were  simply  an  elas- 
tic tube,  it  would  of  necessity  retract  down  upon  the  neck  of  the  foetus 
after  the  passage  of  the  head,  and  thus  a  new  distention  would  be 
required  to  permit  the  passage  of  the  shoulders.  Indeed,  the  condi- 
tions of  an  elastic  tube  are  not  unfrequently  realized  in  versions,  where 
an  attempt  is  made  to  extract  the  foetus  through  an  imperfectly  dilated 
os;  in  which  case,  after  the  disengagement  of  the  shoulders,  the 
cervix  is  apt  to  close  upon  the  neck  and  arrest  the  delivery  of  the 
after-coming  head.  That  this  complication  does  not  happen  as  a  rule, 
is  due  to  the  fact  that  in  natural  labors  the  mechanical  expansion  is 
associated  with  certain  organic  changes,  which  render  the  cervix  soft 
and  distensible  and  at  the  same  time  diminish  its  retractility.  The 
basis  of  the  organic  changes  consists  in  the  serous  infiltration  of  the 
lymphatic  interspaces,  which  separates  the  tissue-elements,  and  de- 
prives them  of  the  resistance  afforded  by  the  force  of  cohesion.  The 
main  factor  in  the  production  of  the  softening  of  the  cervix  is  an 
active  hyperaemia,  which  the  cervix  shares  during  pregnancy  with  all 
the  pelvic  organs,  and  which  during  labor  is  greatly  enhanced  by  the 
diminished  pressure  to  which  the  parts  below  the  pelvic  brim  are 
subjected.     We  have  already  noticed  how,  during  the  acme  of  a  pain, 


THE   PHYSIOLOGY   OF  LABOR.  ;^39 

the  contents  of  the  uterine  vessels  are  forced  into  the  vessels  of  the 
intra-pelvic  viscera. 

In  normal  head  presentations  the  organic  changes  are  in  a  special 
degree  furthered  by  the  formation  of  what  is  known  as  the  bag  of 
waters.  As  the  head  descends  into  the  lower  uterine  segment,  the 
contraction  of  the  muscular  fibers  around  its  largest  circumference 
separates  a  layer  of  fluid  from  the  contents  of  the  uterine  cavity.  At 
first  this  layer  becomes  tense  only  during  a  pain.  With  the  descent 
of  the  head  the  tension  increases,  and  the  '^  bag  of  waters  "  is  formed. 
As  the  abdominal  pressure  is  not  operative  below  the  pelvic  line,  and 
as  the  intra-uterine  pressure  is  arrested  in  a  measure  by  the  child's 
head,  in  that  portion  of  the  uterus  which  lies  below  the  circle  of 
cephalic  compression,  hyperemia,  serous  infiltration,  and  softening  fol- 
low as  necessary  corollaries  of  the  anatomical  conditions.  The  value 
of  the  bag  of  waters  in  dilating  the  cervix  is  due,  therefore,  not  only 
to  the  hydrostatic  pressure  it  exerts,  but  to  the  manner  in  which  it 
favors  the  development  of  the  organic  j^rocesses  described. 

Thus  far  we  have  considered  the  expellent  forces  as  acting  upon 
the  ovum  as  a  whole.  Many  authorities  accept  in  addition  a  direct 
pressure  of  the  fundus  upon  the  breech  of  the  child,  which  is  transmit- 
ted through  the  spinal  column  to  the  cephalic  pole.  A  little  reflec- 
tion, however,  will  show,  as  Lahs*  has  pointed  out,  that  so  long  as  the 
ovum  contains  any  measurable  quantity  of  fluid,  or  at  least  more  than 
enough  to  fill  the  fetal  interspaces,  the  immediate  contact  of  the 
breech  with  the  fundus  is  hardly  possible.  To  be  sure,  Ahlfeld  f  de- 
termined, by  direct  measurements,  that  there  was  an  actual  increase  of 
about  one  and  a  half  inch  in  the  distance  between  the  two  poles  of 
the  child  in  head-presentation^s  during  the  height  of  a  pain.  Schroe- 
der  I  attributes  this  extension  to  the  lateral  compression  of  the  foetus, 
which  results  from  the  diminution  of  the  transverse  diameter  of  the 
uterus  during  contraction  ;  but  it  is  evident  that  lateral  pressure  would 
equally  produce  an  elevation  of  the  fluid  contents  of  the  ovum,  and 
thus,  as  the  fundus  assumes  a  spherical  shape,  prevent  the  impinge- 
ment of  the  breech.  Moreover,  it  is  not  easy  to  see  how,  so  long  as 
the  fwtus  is  surrounded  by  a  fluid  medium,  any  effective  propulsive 
force  can  be  transmitted  through  a  flexible  column  like  the-  spine.  It 
is  certain  that,  in  the  intervals  of  the  pains,  manual  pressure  upon  the 
breech  through  the  fundus  simply  bends  the  fetal  body,  and  deflects  it 
from  the  vertical  direction.  Even  if,  during  a  pain,  the  lessening  of  the 
uterus  in  the  transverse  diameter  hinders  this  movement  to  some 
extent,  the  increase  antero-posteriorly  would  still  leave  ample  space  for 
lateral  incurvation. 

*  Lahs,  Studien  zuriGeburtskunde,  Arch.  f.  Gynaek.,  Bd.  iii,  p.  195. 

•f-  Ahlfeld,  Arch.  f.  Gynaek.,  Bd.  ii,  p.  367. 

I  ScHROEDER,  Lehrbuch  der  Geburtshiilfe,  6te  Aufl.,  p.  15G. 


^^Q  LABOR. 


The  descent  of  the  ovum  is  followed  necessarily  by  increased  ten- 
sion of  the  bag  of  waters.  Under  a  pressure,  estimated  by  Duncan  * 
as  varying,  according  to  the  resistance  of  the  membranes,  between 
four  f  and  thirty-seven  and  a  half  pounds,  rupture  occurs.  The  cervix 
then  usually  closes,  but  remains  dilatable  ;  i.  e.,  it  yields  readily  to 
pressure,  and  offers  no  resistance  to  the  advancing  head. 

The  pressure  exerted  by  the  united  action  of  the  uterine  and  ab- 
dominal walls  requisite  to  accomiilish  delivery,  according  to  the  esti- 
mates of  Schatz,!  based  upon  manometric  observations,  varies  between 
seventeen  and  fifty-five  pounds.*  Although  the  methods  by  which 
both  the  results  of  Schatz  and  Duncan  have  been  obtained  possess 
defects,  which  the  authors  themselves  make  no  attempts  to  conceal, 
they  are  quoted  as  furnishing  approximations  to  the  truth. 


CHAPTER   VIII. 

MECHANISM  OF  LABOR. 

Anatomical  factors. — Anatomy  of  pelvis. — Sacrum. — Coccyx. — Ossa  innominata.— 
The  ilia. — The  pubes. — The  ischia. — Articulations  of  the  pelvis. — Sacro-iliac 
articulations. — Symphysis  pubis. — The  pelvic  ligaments. — Obturator  membrane. 
— Sacro-sciatic  ligaments. — Inclination  of  the  pelvis. — The  pelvis  as  a  whole. — 
The  pelvic  planes. — Plane  of  the  brim. — Plane  of  the  outlet. — Planes  of  the 
cavity. — Ischial  planes. — Pelvic  axis. — Differences  between  male  and  female 
pelvis. — Differences  between  the  infantile  and  adult  pelvis. — The  soft  parts  of 
the  pelvis. — The  perineal  floor. — The  head  of  the  fa?tus  at  term. — Sutures  and 
fontanelles. — The  diameters  of  the  fetal  head. — The  articulation  of  the  head 
with  the  spinal  column. 

The  mechanism  of  labor  comprehends  the  movements  of  adjust- 
ment, by  means  of  which  the  foetus  accommodates  itself  to  the  dimen- 
sions of  the  bony  pelvis  and  to  the  variations  in  the  direction  of  the 
parturient  canal.  Its  study  is,  therefore,  properly  prefaced  by  the 
enumeration  of  a  series  of  anatomical  details  relating  to  the  pelvic 
ring  and  the  soft  tissues  which  form  the  floor  of  the  pelvic  basin, 
and  to  the  structure,  the  diameters,  and  the  reducibility  of  the  fetal 
head. 

*  Duncan,  Researches  in  Obstetrics. 

\  RiBEMONT,  Recherches  experimentales  sur  la  resistance,  etc.,  des  membranes 
de  I'ceuf  humain,  p.  35,  places  the  minimum  resistance  at  fifteen  and  three  fourths 
pounds. 

X  Vide  ScHROEDER,  Lehrbuch,  6te  Aufl.,  p.  158. 

*  PoLAiLLON,  Recherches  sur  la  physiologic  de  I'uterus  gravide,  p.  38,  estimates 
the  minimum  pressure  at  twenty-three  pounds. 


MECHANISM   OB^  LABOR. 


lil 


The  Axatomy  of  the  Pelvis. 

The  following  description  includes  only  such  points  as  are  of  direct 
obstetrical  interest : 

The  bony  pelvis  is  formed  by  the  union  of  the  sacrum  and  coccvx 
and  the  two  ossa  innominata. 

The  Sacrum. — The  sacrum  is  a  curved  quadrilateral  bone,  inserted 
like  a  wedge  between  the  ossa  innominata.  Like  a  wedge,  it  is  broad 
above  and  tapers  toward  its  lower  extremity.  It  is  composed  of  a 
central  vertebral  portion,  and  two  outer  masses  termed  the  ala^  or  wino-s. 
The  central  portion,  as  its  name  implies,  is  really  a  continuation  of 
the  spinal  column.  In  early  childhood  it  consists  of  five  distinct  ver- 
tebrae with  well-defined  joint-surfaces  and  intermediate  cartilaginous 


RBONIONTORV, — ' 


LINEA 
TRANSVERSALIS. 


Fig.  68.— Sacrum  and  coccyx  (anterior  surface). 

disks ;  but  with  the  completion  of  the  growth  the  whole  becomes  con- 
solidated into  a  single'  piece  by  the  inter-articular  deposition  of  bone. 
The  bony  union  is  confined  chiefly  to  the  outer  circumference,  and  is 
marked  by  ridges  termed  the  linece  ti^ansverscB.  The  base  of  the 
sacrum  articulates  with  the  last  lumbar  vertebra,  with  which  it  forms 
a  projecting  angle.  It  possesses  a  convex  anterior  surface,  termed  the 
promontor}^  which  juts  forward  and  encroaches  upon  the  pelvic  space. 
From  the  sides  of  the  central  piece  there  extend  two  triangular 
portions  of  bone,  termed  the  alte  or  wings.  Under  normal  conditions 
they  are  symmetrical.  They  are  developed  upon  each  side  from  three 
independent  nuclei,  which  make  their  appearance  near  the  bodies  of 
the  three  upper  vertebrse.  They  are  supposed  to  have  the  morphological 
significance  of  ribs.  In  the  course  of  this  growth  they  fuse  together, 
except  at  the  points  of  junction  of  the  bodies  of  the  vertebra?,  where 
they  leave  between  them  open  spaces  or  foramina,  for  the  passage  of 
the  spinal  nerves. 


142 


LABOR. 


The  sacrum  in  the  female  is  about  four  and  a  half  inches  wide,  and 
from  four  to  four  and  a  half  inches  long,  when  measured  from  the 
promontory  to  the  lower  extremity.  The  sacrum  possesses  two  curves : 
one,  less  marked,  from  §ide  to  side,  and  the  other  extending  from 
above  downward.  The  depth  of  the  latter  is  greatest  just  below  the 
upper  border  of  the  third  vertebra,  where  it  measures  a  little  over  an 

inch. 

Upon  the  posterior  surface  we  notice  a  canal,  continuous  with  the 
spinal  canal,  which  runs  the  entire  length  of  the  sacrum,  but  is  incom- 
pletely closed  at  the  fifth  vertebra,  giving  rise  to  a  slit-like  opening, 
termed  the  hiatus  sacraUs.  In  the  middle  line  the  spinous  processes 
coalesce  into  a  vertical  crest  for  the  attachment  of  the  erector  spinas 
muscle.  The  posterior  lateral  masses  are  formed  by  the  fusion  of  the 
transverse  processes  and  their  consolidation  with  the  anterior  struct- 
ures. Next  to  the  vertebra?,  however,  spaces  are 
left  between  the  processes  for  the  passage  of  the 
posterior  sacral  nerves.  Opposite  the  three  upper 
vertebrae,  the  outer  border  is  known  as  the  tuber- 
osity of  the  sacrum.  It  possesses  a  roughened 
surface,  to  which  are  attached  the  sacro-iliac  liga- 
ments. 

The  upper  portion  of  the  side  of  the  sacrum  is 
furnished  witli  an  ear-shaped  articulating  surface 
termed  the  superficies  auricnlaris. 

The  Coccyx. — The  coccyx  is  composed  of  four 
rudimentary  vertebrae,  which  progressively  dimin- 
ish in  size  from  above  downward.  It  possesses 
as  a  whole,  therefore,  a  triangular  shape.  It  is 
attached  to  the  extremity  of  the  sacrum  by  a  hinge- 
joint,  and  is  pushed  backward  during  defecation, 
and  in  childbirth  as  the  head  passes  the  jielvic  outlet.  It  is  only  when 
anylchosed  that  the  coccyx  assumes  obstetrical  importance. 

The  Ossa  Innominata. — Each  os  innominatum  may  be  roughly  com- 
pared to  a  figure  eight,  of  which  the  ujiper  and  larger  portion  slants 
upward,  outward,  and  backward,  while  the  lower  smaller  division  in- 
clines downward  and  inward.  Up  to  the  age  of  puberty  it  consists 
really  of  three  bones,  which  are  connected  at  the  acetabulum  by  car- 
tilage of  a  Y-shape.  These  three  bones  are  termed  respectively  the 
ilium,  the  ischium,  and  the  pubes,  names  wdiich  are  subsequently  re- 
tained for  convenience  of  description,  in  spite  of  the  fact  that  in  adult 
life  the  separate  parts  become  solidly  united,  by  the  deposition  of  bone- 
tissue,  into  a  single  continuous  piece. 

The  iliac  portion  has  an  external  surface  marked  by  a  number  of 
roughened  lines,  to  which  are  attached  the  three  gluteal  muscles.  The 
inner  surface  is  excavated  and  forms  the  so-called  iliac  fossa,  which 


Fig.  69.— Section  of  sa 
crum  and  coccyx. 


MECHANISM   OF   LABOR. 


143 


contains  the  internal  iliac  muscle.     The  fossa  is  bounded  below  by  the 
linea  arcuata  interna,  a  convex  ridge  which  contributes  to  form  the 


Fig.  70.— Os  innominatum,  before  consolidation.    1,  ilium  ;  2,  ischium  ;  3,  pubes. 

brim  of  the  pelvis.     The  upper  border  or  crest  of  the  ilium  possesses 
an  S-shaped  curve,  the  anterior  extremities  of  which  are  directed  in- 


CREST. 


ANT.  SOP 
SPINOUS    ER0CEG9. 


LESSER 
SCIATIC  NOTCH 


TUBEROSITY 
OF  ISCHINUM 


OBTURATOR  TORAMEN. 
Fig.  71.— Outer  surface  of  os  innominatum. 


ward.     The  crest  of  the  ilium  terminates,  front  and  rear,  in  bony 
prominences,  termed  respectively  the  anterior  and  posterior  superior 


144 


LABOR. 


spinous  processes.  Beneath  the  upper  spines,  and  separated  from  them 
by  curved  indentations,  are  two  lower,  less  sharply  defined  projections, 
termed  the  anterior  and  posterior  inferior  spinous  processes.  Behind 
the  iliac  fossa  is  situated  an  ear-shaped  articular  surface,  the  super- 
ficies auricularis,  which  corresponds  to  the  surface  of  similar  name 
described  upon  the  sides  of  the  sacrum. 

The  pubic  portion  consists  of  the  body  and  two  rami.  The  body 
presents  upon  its  inner  border  an  oval  surface,  which  articulates  with 
the  pubic  bone  upon  the  opposite  side.  The  superior  border  is  fur- 
nished with  a  rough  crest,  terminating  in  the  projecting  spine.  The 
upper,  or,  as  it  is  usually  designated,  the  horizontal  ramus,  possesses 
a  ridge,  the  pecten  pubis,  extending  from  the  spine  and  becoming  con- 


CREST. 


FOSS/l. 


SUPERFICIES 
AURICULARIS. 
LINE. 

NOTCH., 


MNE  OF  ISCHIUM 
LESSER  SCIATiC  NOTCH 


rUBEROSITVOr  ISCHIUM. 
Fig.  72.— Inner  surface  of  os  innominatum. 


tinuous  with  the  linea  arcuata  of  the  ilium.  The  linea  terminalis,  or 
boundary-line  of  the  pelvic  brim,  is  generally  known  as  the  ilio-pec- 
tineal  line,  from  its  sources  of  origin.  Near  the  junction  of  the  ilium 
and  OS  pubis  is  situated  a  slight  elevation,  the  ilio-pectineal  eminence, 
which,  however,  according  to  Luschka,*  belongs  entirely  to  the  pubic 
bone.  The  descending  ramus  helps  to  bound  the  obturator  foramen, 
and  to  form  the  pubic  arch.  The  ischium  completes  the  lower  portion 
of  the  OS  innominatum.  It  consists  of  two  rami,  which,  with  the  rami 
of  the  pubic  bones,  include  the  obturator  foramen.  It  contributes  about 
two  fifths  to  the  formation  of  the  acetabulum ;  from  this  the  descend- 

*  Luschka,  Die  Antoraie  des  raenschlichen  Beckens,  p.  86. 


MECHANISM   OF   LABOR.  j^g 

ing  ramus  drops  vertically  downward,  and  thence  curves  forward,  and 
forms  the  ascending  ramus,  which  unites  with  the  descending  ramus 
of  the  pubes.  At  the  point  where  the  descending  ramus  hooks  forward 
there  is  a  thickened  projection,  termed  the  tuberosity  of  the  ischium, 
upon  which  the  body  rest  in  the  sitting  posture.  Upon  the  posterior 
border  of  the  descending  ramus  there  is  a  sharp  spine,  projecting 
inward,  which  plays  an  important  part  in  the  mechanism  of  labor. 
Between  the  posterior  inferior  spinous  process  and  the  spine  of  the 
ischium  there  is  a  deep  incurvation,  termed  the  great  sciatic  notch; 
while  a  smaller  incurvation,  between  the  spine  and  the  tuberosity,  is 
known  as  the  small  sciatic  notch. 

The  Pelvic  Articulations. — The  articulations  of  the  ossa  innominata 
with  the  sacrum  are  usually  termed  the  sacro-iliac  synchondroses.     The 


L 


Fig.  73.— Section  through  the  left  sacroiliac  articulation  (natural  size).    (Luschka.) 

anterior  articulation  of  the  innominate  bones  with  one  another  is  known 
as  the  symphysis  pubis. 

The  term  "  synchondrosis,"  as  applied  to  the  sacro-iliac  articulation, 
is  really  a  misnomer.  Luschka  has  shown  that,  in  place  of  an  inter- 
vening plate  of  cartilage,  section  demonstrates  the  existence  of  a  true 
synovial  membrane,  limiting  a  narrow  but  well-defined  joint-cavity. 
The  middle  third  of  the  iliac  surface  is  convex,  and  fits  into  a  corre- 
sponding concave  depression  on  the  sacral  end.  There  is  likewise  a 
.  "bite"  or  ledge  in  front,  formed  by  the  ilium,  which  aids  in  prevent- 
ing the  sacrum  from  slijpping  forward  into  the  pelvic  cavity. 
10 


146 


LABOR. 


The  office  of  maintaining  the  sacrum  in  position  devolves  chiefly 
upon  the  ligaments  distributed  front  and  rear,  and  particularly  upon 
the  very  numerous  and  closely  interwoven  bundles  extending  from  the 
tuberosities  of  the  sacrum  to  the  roughened  portions,  or  tuberosities, 
of  the  ilia,  which  project  posteriorly  beyond  the  articulation. 

The  symphysis  pubis  is  likewise  supplied  with  a  small  cavity,  only 
the  posterior  portion  of  which  possesses  a  synovial  membrane.  '  The 


Fig.  74.— Section  of  symphysis.    (Luschka.) 

fibro-cartilage  between  the  articulating  surfaces  of  the  bones  is  thicker 
in  front  than  behind.  The  anterior  ligaments  are  more  developed  than 
the  posterior  ones,  and  allow  no  movements  of  importance  to  take 
place  in  the  non-pregnant  condition. 

The  Pelvic  Ligaments. — In  addition  to  the  ligaments  which  have 
already  been  noticed  as  contributing  to  the  solidity  of  the  joints,  the 


ILIO-FEMORAL 
LIGAMENT. 


—i^SACSOSCIATO 
LIGAMENT 


Fig.  75.— Front  view  of  pelvis,  with  ligaments.    (Qiiain.) 


MECHANISM  OP  LABOR. 


147 


following  help  to  close  in  the  pelvis.  Across  the  obturator  foramen  is 
stretched  a  fibrous  septum,  complete  except  where  a  small  opening  is 
left  for  the  passage  of  the  nerve  and  vessels. 

The  great  sacro-sciatic  ligament  extends  partly  from  the  lower  bor- 
der of  the  sacro-iliac  articulation,  and  partly  from  the  lower  border  of 


GREAT  SCIATIC 
FORAMEN. 


SMALL  SCIATIC 
LIGAMENT. 


SMALL  SCIATIC  FORAMEN 


GREAT  SCIATIC  LIGAMENT. 


Fig.  76.— Transverse  section  through  pelvis,  to  show  the  sacro-sciatic  ligaments. 
(Taruier  et  ChantreuiL) 

the  sacrum  and  coccyx,  to  the  tuberosity  of  the  ischium.  The  small 
sacro-sciatic  ligament  lies  in  front  of  the  preceding,  and  extends  from 
the  side  of  the  sacrum  and  coccyx  to  the  spinous  process  of  the 
ischium.  These  two  ligaments  close  the  large  and  small  sacro-sciatic 
notches,  and  convert  them  into  two  foramina,  which  bear  the  same 
name.  » 

The  Inclination  of  the  Pelvis. — The  plane  of  the  brim  of  the  pelvis 
was  formerly  supposed  to  run  nearly  parallel  to  the  horizon,  whence 
the  term  "horizontal  ramus,"  applied  to  the  upper  branch  of  the 
pubes.  As  a  fact,  however,  in  the  upright  position,  the  inclination  of 
the  brim  to  the  horizon  varies  from  45°  to  100°.  According  to  Meyer, 
the  center  of  gravity,  instead  of  passing  directly  througli  the  median 
line  of  the  acetabula,  is  situated  somewhat  posteriorly,  so  that  a  tilting 
of  the  pelvis  backward  is  only  prevented  by  the  strong  ilio-femoral 
ligaments  (Fig.  75).  Whatever,  therefore,  serves  to  relax  the  ligaments 
in  question  diminishes  the  angle  of  inclination,  while  positions  that 
increase  the  natural  tension  cause  the  pelvis  to  assume  a  nearly  vertical 
attitude.  Experimentally  Meyer  found  that  the  pelvic  inclination  was 
diminished  to  the  greatest  extent  when  the  thighs  were  moderately 
separated  and  rotated  slightly  inward,  while  its  increase  was  due  to  four 
conditions :  closing  the  knees,  stretching  the  legs  widely  apart,  exter- 
nal rotation,  and  exaggerated  internal  rotation.     Naegele  endeavored 


148 


LABOR. 


to  ascertain  the  normal  inclination  upon  the  living  subject,  by  detei- 
mining  the  distance  between  the  extremity  of  the  coccyx  and  a  hori- 
zontal line  drawn  from  the  lower  border  of  the  symphysis,  and  then 
placing  the  bony  pelvis  in  a  position  conforming  to  the  measurement 


COCCYX  V 


PUSHED  BACK 


OBSTETRICAL    CONJUGATE 


HORIZON 


PLANE  OF  OUTLET 

clination  of  the  pel 
(Taruier  et  Chantreuil.) 


Fig.  77.— Section  showing  the  incUnation  of  the  pelvis  according  to  Xaegele. 
-       if.) 


thus  obtained.  He  found  in  this  way  that  the  mean  inclination  was 
nearly  60°,  a  result  explained  by  the  fact  that  the  method  of  measure- 
ment rendered  a  separation  of  the  knees,  and  consequently  an  increase 
of  tension  of  the  ilio-femoral  ligaments,  a  matter  of  necessity.* 

Movements  at  the  Pelvic  Akticulations. 

At  the  symphysis  pubis  during  gestation  the  fibers  which  compose 
its  fibro-cartilage  become  infiltrated  with  serum,  and  the  ligaments 
elongate,  so  that  at  term  the  distance  between.the  articular  surfaces  of 
the  pubic  bones  is  increased  twofold.  Budin  has  shown  that  if  the 
patient,  when  the  finger  is  introduced  into  the  vagina  and  pressed 
upward  against  the  lower  border  of  the  symphysis,  be  made  to  walk, 
an  elevation  of  the  ramus  upon  the  side  of  the  extremity  in  motion 
can  be  distinctly  recognized.  In  the  rule,  this  mobility  is  most 
marked  in  women  who  have  borne  a  number  of  children.f 

Zaglass  first  pointed  out  that,  in  spite  of  the  close  union  at  the 

*  ScHROEDER,  Lchrbuch  der  Geburtshiilfe,  6te  Aufl.,  note,  p.  7 :  Xaegele,  8te 
Aufl.,  p.  81. 

f  Tarnier  et  Chantreuil,  Traite  de  I'art  des  accouchements,  p.  239. 


MECHANISM   OF  LABOR. 


149 


Fig.  78. — Diagram  showing  oscillatory  move- 
rueuts  of  sacrum.    (Duncan.) 


sacro-iliac  articulation,  a  certain  degree  of  mobility  between  the  sacrum 
and  iliac  bones  existed.  Thus,  in  defecation,  when  the  body  is  thrown 
forward,  the  promontory  is  tilted  toward  the  symphysis,  and  the  in- 
ferior extremity  of  the  sacrum  is  thrown  backward,  thereby  enlarging 
the  outlet  of  the  pelvis.  Matthews  Duncan  describes  similar  move- 
ments, only  exaggerated  in  extent,  during  pregnancy,  and  points  out 
how  they  practically  contribute  to  facilitate  labor.  Thus,  at  the  be- 
ginning of  labor,  as  the  head  enters  the  brim,  the  woman  naturally 
chooses  to  sit  up,  to  walk  about, 
or,  if  in  bed,  to  recline  with  the 
lower  extremities  extended  —  posi- 
tions which  favor  the  rotation  back- 
ward of  the  upper  portion  of  the 
sacrum,  and  the  consequent  increase 
of  the  antero-posterior  diameter  at 
the  superior  strait.  As  the  head, 
however,  descends  to  the  floor  of 
the  pelvis,  the  patient  instinctively 
draws  up  her  knees,  throws  the 
body  forward,  and  during  a  pain 
contracts  the  abdominal  muscles. 
In  this  way  she  succeeds  in  tilting 
up  the  pubes,  in  pressing  the  promontory  forward,  and  in  rotating  the 
point  of  the  sacrum  backward,  so  as  to  perceptibly  increase  the  conju- 
gate diameter  at  the  pelvic  outlet. 

The  Pelvis  as  a  Whole. — The  pelvis  is  divided  by  the  linea  termi- 
nalis  into  an  upper  and  lower  portion. 

The  upper,  or,  as  it  is  usually  termed,  the  large  pelvis,  is  composed 
of  the  lumbar  vertebrae  and  the  upper  surfaces  of  the  wings  of  the 

sacrum  behind,  the  spreading 
portions  of  the  ilia  upon  the 
sides,  while  the  anterior  seg- 
ment is  closed  in  by  the  mus- 
cles of  the  abdominal  parietes. 
In  shape,  the  bony  part  of 
the  large  pelvis  has  been  com- 
pared to  the  rim  of  a  barber's 
basin.  Obstetrically  the  iliac 
fossae  are  of  interest,  inasmuch 
as  they  furnish  shelves  upon 
whicli  the  head  of  the  fwtus 
in  multipara?  commonly  rests 
during  the  latter  part  of  pregnancy.  The  inclination  of  the  ilia  to 
the  horizon,  the  shape  of  the  crests,  and  the  distance  between  the  two 
anterior  superior  spinous  processes,  are  important  points  for  study, 


Fig.  79.— Anterior  half  of  the  pelvis. 


150 


LABOR. 


Fig.  80.— Posterior  Jialt"  of  the  pelvis. 


because  they  furnish  data  upon  which  vahiable  inferences  are  based, 
in  cases  of  pelvic  deformity,  relative  to  the  shape  and  dimensions  of 
the  pelvic  canal. 

It  will  be  remembered  that  the  crests  of  the  ilia  possess  an  S-shaped 
curve.  JSTormally,  the  widest  distances  between  the  crest  measure  ten 
inches;  the  distance  between  the  anterior  superior  spinous  processes 
measures  nine  inches.*     The  slope  of  the  inner  surfaces  of  the  ilia  is 

such  that  an  extension  of  the 
lines  drawn  from  the  crest  to 
the  linea  terminalis  would  meet 
in  the  neighborhood  of  the 
fourth  sacral  vertebra. 

The  inferior  or  small  pelvis 
comprises  the  portion  below 
the  linea  terminalis.  It  is 
formed  by  the  sacrum,  the 
coccyx,  the  lower  portion  of 
the  ilia,  the  ischia  and  pubes, 
the  obturator  membrane,  and 
the  sacro  -  sciatic  ligaments. 
Together  the  foregoing  inclose  a  basin-like  cavity,  which,  though  open 
below  in  the  skeleton,  is  closed  in  by  soft  parts  in  the  living  subject. 
The  posterior  wall,  formed  by  the  sacrum  and  coccyx,  measures  five 
inches  in  a  direct  line  from  the  promontory  to  the  a2)ex  ;  the  anterior 
wall  at  the  Symphysis  jjubis  measures  one  and  three  quarters  inch  ;  the 
lateral  walls,  from  the  linea  terminalis  to  the  tuberosities  of  the  ischia, 
measure  three  and  three  quarters  inches.  The  posterior  wall  is  curved ; 
the  symphysis  pubis  slo^aes  downward  and  inward,  so  as  to  run  nearly 
parallel  with  the  two  upper  sacral  vertebrae ;  the  rami  of  the  pubes 
approach  one  another  at  an  angle  of  95°  to  100°,  and  unite  beneath 
the  symphysis  in  the  form  of  an  arch,  the  arcus  pubis ;  the  side  walls 
are  solid  in  front  where  they  are  constituted  by  the  ischia,  while  be- 
hind the  great  sciatic  notch  is  closed  only  by  soft  structures  and  the 
sacro-sciatic  ligaments.  The  transverse  diameter,  owing  to  the  incline 
of  the  side  walls,  narrows  toward  the  outlet. 

The  Planes  and  Axes  of  the  Pelvis.— The  eccentric  forms  of  the 
pelvic  bones  render  it  extremely  difficult  to  convey  a  clear  impression 
of  the  nature  of  the  pelvic  inclosure.     As  a  means  to  this  end,  it  is 

*  As  no  two  pelves  possess  precisely  the  same  dimensions,  pelvic  measurements 
are  given  somewhat  differently  by  authors.  They  are  obtained  either  by  taking 
the  mean  of  a  large  number  of  pelves  (a  method  which  furnishes  fractions  difficult 
to  remember,  but  offering  no  special  advantages  in  the  way  of  accuracy),  or  by 
selecting  as  the  normal  standard  either  a  whole  number,  or,  where  fractions  are 
necessary,  the  nearest  half  or  quarter  approximating  to  the  mean  average.  The 
latter  plan  recommends  itself  in  practice  equally  on  the  score  of  utility  and  con- 


MECHANISM   OF   LABOR. 


151 


customary  to  study  a  series  of  planes  drawn  at  different  levels  through 
the  pelvic  walls,  which  serve  to  show  the  changes  in  the  shape  and 
dimensions  of  the  bony  canal  at  selected  points  of  observation.  By  a 
plane  is  meant  simply  a  mathematical  surface,  without  reference  to 
depth  or  thickness. 

The  upper  and  lower  openings  are  both  somewhat  contracted,  and 
hence  are  termed  respectively  the  superior  and  inferior  straits,  while 
the  space  between  is  denominated  the  cavity  of  the  pelvis. 

The  first  plane  requiring  our  attention  is  that  of  the  superior  strait 
or  brim.     It  is  bounded  by  the  linea  terminalis,  and  has  an  elliptical 


OlSTANnE  BETWEEN 
THE  CRESTS  lOIN. 

DISTANCE  BETWEEN 
ANIT.SUP.SP  PR0C.9IH. 
SACRD  COTYLOID. 

OBLIQUE  DIAMETER  SIN. 


CONJUGATE    4 '/♦!»». 

Fig.  8].— Diameters  of  the  brim. 


contour,  with  a  depression  posteriorly,  produced  by  the  projection  of 

the  promontory  of  the  sacrum. 

The  dimensions  of  each  plane  are  determined  by  measuring  the 

an tero  -  posterior,  the  trans- 
verse, and  the  two  oblique 
diameters. 

The  antero-posterior,  or, 
as  it  is  generally  termed,  the 
conjugate  diameter,  extends 
from  the  upper  border  of  the 
symphysis  pubis  to  the  prom- 
ontory. Its  length  is  four 
and  a  quarter  inches.  About 
two  fifths  of  an  inch  below 
the  upper  border  of  the  sym- 
physis is  situated  the  obstet- 
rical, as  distinguished  from 

the  anatomical,  conjugate.     The  length  of  the  former,  owing  to  the 

thickening  of  the  pubic  bones,  is  reduced  to  four  inches. 

The  transverse,  sometimes  termed  the  bis-iliac,  diameter  is  the  widest 

distance  between  the  ilia.     It  measures  five  and  a  quarter  inches. 


Fig.  82.— Diameters  of  the  outlet. 


152 


LABOR. 


The  oblique  diameters  extend  from  the  ilio-pectineal  eminences  to 
the  opposite  sacro-iliac  articulations.  The  distance  between  the  points 
mentioned  is  five  inches.  The  right  oblique  diameter  is  the  one 
directed  to  the  right,  and  the  left  to  the  left  sacro-iliac  articulation. 

The  axis  of  the  superior  strait  is  represented  by  a  line  drawn  per- 
pendicular to  the  center  of  the  plane.  The  extension  of  this  line  falls 
below  upon  the  extremity  of  the  coccyx,  and  above  strikes  the  abdo- 
men near  the  umbilicus  {vide  Fig.  98).  The  circumference  of  the 
brim  is  very  nearly  sixteen  inches. 

The  inferior  strait  proper,  or  outlet  of  the  pelvis,  is  bounded  by 
the  sub-pubic  ligament,  the  pubic  rami,  the  rami  and  tuberosities  of 
the  ischia,  the  sciatic  ligaments,  and  the  coccyx.  Owing  to  the  pro- 
jection of  the  ischia,  the  surface  of  the  pelvic  outlet  is  rendered  con- 
vex, or,  perhaps,  is  better  described  by  supposing  it  to  be  composed 


OBSTETRICAL    CONJUGM"E. 


HORIZON 


aUSBED  BACK 


Fig.  83.— Section  showing  thb  inclination  of  the  pelvis  according  to  Naegele. 
(Tarnier  et  Chantreuil. ) 


of  two  obtuse-angled  triangles  with  apices  at  the  symphysis  and 
coccyx,  and  witli  a  common  base  formed  by  a  line  drawn  through  the 
ischia. 

The  antero-posterior  diameter  extends  from  the  lower  border  of 
the  symphysis  to  the  extremity  of  the  coccyx.  It  measures  three  and 
three  quarters  inches,  though,  when  the  coccyx  is  pushed  backward, 
the  distance  may  be  extended  to  four  and  a  half  inches. 

The  transverse  diameter  between  the  inner  borders  of  the  tuberoS' 
ities  measures  four  and  a  quarter  inches. 


MECHANISM   01'   LABOR. 


153 


Owing  to  the  elasticity  of  the  sciatic  ligaments,  the  oblique  diam- 
eters are  not  regarded  as  of  obstetrical  importance. 

The  axis  of  the  inferior  strait,  when  the  coccyx  is  not  disturbed 
strikes  the  promontory.  When  the  coccyx  is  pushed  backward,  a  per- 
pendicular line  drawn  from  the  center  impinges  upon  the  lower  bor- 
der of  the  first  sacral  vertebra. 

The  circumference  of  the  inferior  strait  measures  thirteeen  and  a 
half  inches. 

The  pelvic  cavity  or  canal  possesses  an  irregular,  cylindrical  shape, 
constricted  somewhat  above  at  the  superior  strait,  and  narrowing  rap- 
idly at  the  pelvic  outlet.  Below  the  brim  the  dimensions  are  in- 
creased considerably  by  the  concavity  of  the  sacrum.  Thus,  a  plane 
passing  through  the  lower  portion  of  the  symphysis  pubis,  and  across 
the  upjjer  margins  of  the  acetabula,  to  the  junction  of  the  second  and 
third  sacral  vertebrse,  gains  three  quarters  of  an  inch  in  the  conjugate, 
while  the  transverse  diameter  is  barely  one  fourth  of  an  inch  less  than 
the  transverse  diameter  of  the  brim.  The  narrowing  at  the  outlet  is 
most  marked  in  a  j)lane  drawn  so  as  to  intersect  the  spines  of  the 
iscliia  and  the  extremity  of  the  sacrum.  At  the  level  indicated,  the 
distance  between  the  spines  (transverse  diameter)  is  but  four  inches, 
and  the  antero-posterior  diameter  four  and  a  half  inches. 

The  sciatic  spines  divide  the  pelvic  cavity  into  two  unequal  sec- 
tions. In  the  larger,  anterior  section,  the  lateral  walls  slope  toward 
the  symphysis  and  arch  of  the  pubes,  while 
posteriorly  the  walls  slope  in  the  direction 
of  the  sacrum  and  coccyx.  The  declivities 
in  front  of  the  spines  are  termed  the  an- 
terior inclined  planes  of  the  pelvis,  over 
which  rotation  of  the  occiput  takes  place  in 
the  mechanism  of  normal  labor.  Behind 
the  spines  the  lateral  slopes  are  known  as 
the  posterior  inclined  planes.  Meeting  to- 
gether in  the  median  line  of  the  sacrum, 
they  constitute  a  sort  of  vault,  into  which  the 
face  is  turned  after  rotation  is  completed. 

The  general  direction  of  the  pelvic  cav- 
itv  is  best  shown  by  a  line  representing  the 

axis  of  tlie  bony  channel.  It  should,  however,  be  stated  in  advance 
that  the  so-called  pelvic  axis  of  obstetrical  writers  is  not  to  be  con- 
strued as  the  median  line  of  a  cylinder  in  a  strict  mathematical  sense, 
but  is  really  intended  to  indicate  very  nearly  the  course  which  a  round 
body  like  the  fetal  head  would  naturally  pursue  in  its  course  through 
the  parturient  canal.  In  practice  it  is  convenient  to  follow  the  sugges- 
tion of  Hodge,  and  draw  a  plane  from  the  supra-pubic  ligament  back- 
ward to  the  sacrum,  and  parallel  to  the  plane  of  the  superior  strait. 


Fig.  84 


Axis  represented  upon  a 
vertical  section  through  a  plas- 
ter cast  of  ihe  pelvic  cavity. 
(Hodge.) 


154 


LABOR. 


This  second  parallel  would  intersect  the  middle  portion  of  the  second 
sacral  vertebra.  Inasmuch  as  the  pubic  walls  run  nearly  parallel  to 
the  upper  portion  of  the  sacrum,  the  axis  of  the  cavity  included  be- 
tween the  two  planes  may  be  regarded  as  continuous  with  the  axis  of 
the  brim.  Below  the  second  plane,  owing  to  the  curvature  of  the 
sacrum,  the  axis  describes  a  nearly  circular  course,  with  intersecting 
planes  radiating  from  the  lower  border  of  the  symphysis  as  a  center. 
Further  on  it  will  be  shown  that  the  axial  curve  is  continued  beyond 
the  bony  canal  by  the  distended  tissues  which  form  the  floor  of  the 
pelvic  basin 

Differences  between  the  Male  and  Female  Pelvis. — In  the  male,  the 
0  bones   of  the  pelvis  are  thick  and  solid ;  the  brim  is  triangular   in 

shape ;  the  promontory  projecting ; 
the  cavity  deep,  and  sloping  inward 
like  a  funnel ;  the  sacrum  long, 
narrow,  and  moderately  curved  ; 
and  the  arch  of  the  pubes  is  formed 
at  an  angle  of  from  75°  to  80°.  In 
the  female,  on  the  contrary,  the 
bones  are  lighter  and  more  delicate 
in  contour,  therein  corresi)onding 
to  the  inferior  muscular  develop- 
ment of  the  sex ;  thc^brim,  owing 
to  the  less  marked  Jutting  inward 
of  the  i^romontory,  has  an  ellipti- 
cal outline ;  the  diameters,  both 
antero-posterior  and  transverse,  are 
increased ;  the  pelvic  inclination 
is  more  pronounced  ;  the  sacrum 
is  wider  and  more  concave ;  the 
tuberosities  of  the  ischia  are  wider 
apart ;  the  angle  of  the  arch  of  the 
pubes  measures  from  90°  to  100° ; 
and  the,  entire  depth  of  the  pelvis 
is  diminished.  As  a  result  of  the 
increased  transverse  diameter  in 
the  female,  the  trodianters  are  at 
a  greater  relative  distance  from  one  another,  and  are  directed  some- 
what obliquely  to  the  front.  This  peculiarity  brings  the  knees  in 
close  proximity,  and  accounts  for  the  characteristic  feminine  gait. 

The  configuration  of  the  female  pelvis,  though  unfavorable  to 
rapid  locomotion,  is  in  a  special  degree  adapted  to  render  possible 
the  birth  of  the  child.  A  female  pelvis  approximating  in  type  to 
that  of  the  male  gives  rise  to  a  variety  of  dystocia  of  a  very  formid- 
able character. 


Fig.  85. 


-Vertical  section  of  a  female  infantile 
pelvis.    (Fehling.) 


MECHA^^ISM   OF   LABOR. 


155 


Differences  between  the  Infantile  and  Adult  Pelvis.— In  the  in- 
fantile pelvis  the  promontory  occupies  a  relatively  higher  position 
above  the  upper  border  of  the  symphysis ;  the  last  lumbar  and  two 
upper  sacral  vertebrse  possess  a  moderate  convexity — i.  e.,  the  prom- 
ontory does  not  project  forward,  as  in  the  adult ;  the  sacrum,  after 
running  a  straight  course,  begins  to  curve  forward  first  at  the  fourth 
vertebra;  the  alse  are  slightly  developed;  the  inclination  of  the  ilia 
more  nearly  approaches  the  perpendicular ;  the  S-shaped  curve  of  the 
crests  is  barely  indicated,  there  being  but  slight  difference  in  the  dis- 
tances between  the  crests  and  anterior  superior  spines ;  the  conjugate 
diameter  in  proportion  to  the  transverse  is  increased;  the  side-walls 
converge  toward  the  outlet ;  the  pubic  arch  is  formed  at  an  acute 
angle  ;  and  the  distance  between  the  spines  of  the  ischia  is  greater  than 
the  transverse  diameter  of  the  outlet. 

Distinctions  pertaining  to  sex  are  but  slightly  accentuated.  In  the 
female,  the  sacrum,  owing  to  the  smaller  size  of  the  vertebrae,  is 
narrower  than  in  the  male ;  the  side  walls  are  higher ;  the  symphysis 


Figs.  86,  87.— Diagrammatic  representations  of  sections  through  the  infantile  and  adult  pelves. 

(Schroeder.) 

lower ;   the  iliac  incline  approaches  more  nearly  a  vertical  line ;  the 
pubic  arch  is  less  acute ;  and  the  transverse  diameter  is  increased. 

The  most  important  agent  in  effecting  the  changes  which  char- 
acterize the  adult  pelvis  is  unquestionably  the  weight  of  the  trunk. 
Owing  "to  the  wedge-shape  of  the  sacrum,  and  the  shelf-like  ledge 
which  projects  from  the  lower  surface  of  the  iliac  articulation,  no  dis- 
placement can  take  place  in  the  direction  of  the  long  axis  of  the  au- 
ricular surfaces.  But,  when  we  bear  in  mind  the  inclination  of  the 
pelvis,  it  is  obvious  that  pressure  from  above  must  act  upon  the  sa- 
crum likewise  in  a  downward,  forward,  and  inward  direction.  Now,  if 
the  sacrum  were,  as  it  is  sometimes  represented,  the  key-stone  of  the 
pelvic  arch,  its  position  would  be  fixed  between  the  ilia.     We  owe  to 


156  LABOR. 

Duncan,*  however,  the  demonstration  that  this  view  is  incorrect,  and 
that  in  reality  the  sacral  articulation  slopes  backward  and  inward  in 
the  direction  of  the  median  line.  The  fact  that  the  sacrum  does  not 
under  pressure  drop  from  the  arcli  is  due  to  the  strong  sacro-iliac 
ligaments,  which  hold  it  in  position  as  part  of  the  bony  ring.  The 
ligaments  do  not,  however,  prevent  the  sacrum  from  sinking  forward 
to*a  limited  extent  into  the  pelvic  cavity,  as  is  shown  in  the  projection 
backward  at  maturity  of  the  tuberosities  of  the  ilia,  whereas  in  the 
infantile  pelvis  the  dorsal  surface  of  the  sacrum  is  level  with  the  pos- 
terior superior  spinous  processes. 

As  the  line  of  gravity  of  the  trunk  falls  in  front  of  the  sacrum, 
the  weight  from  above  presses  the  promontory  forward  and  inward 
toward  the  symphysis  pubis.  At  the  same  time  the  rotation  backward 
of  the  sacral  apex  is  restrained  by  the  sciatic  ligaments.  The  natural 
effect  of  these  two  simultaneously  operative  forces,  acting  at  a  period 
when  ossification  is  still  incomplete,  is  to  increase  the  sacral  curve, 
and  consequently  to  shorten  the  distance  between  the  upper  and  lower 
ends  of  the  base.  As  a  result,  the  height  of  the  promontory  is  dimin- 
ished, the  pelvic  brim  and  outlet  become  constricted,  and  the  dimen- 
sions of  the  pelvic  cavity  are  increased.  The  upper  portion  of  the 
sacrum,  in  rotating  forward,  drags  upon  the  posterior  ligamentous  at- 
tachments of  the  ilia.  This  traction  would,  were  it  not  for  their  union 
at  the  symphyses  and  the  pressure  of  the  heads  of  the  thigh-bones, 
cause  the  ossa  innominata  to  revolve  around  the  sacral  articular  sur- 
faces, like  doors  upon  their  hinges.  As  a  result  of  the  antagonistic 
action  of  the  symphysis  and  the  sacro-iliac  ligaments,  however,  the 
ossa  innominata  bend  at  the  point  of  least  resistance  in  front  of  the 
sacrum,  and  in  this  way  an  increase  takes  place  in  the  transverse  at  the 
expense  of  the  antero  posterior  diameter. 

The  sexual  differences  are  attributable  to  differences  in  the  char- 
acter of  the  pelvic  contents  and  the  external  sexual  organs,  to  differ- 
ences in  muscular  development,  and  to  certain  distinctive  peculiarities 
of  growth.  Thus,  in  the  female  eunuchs  of  India,  described  by 
Koberts,f  there  were  absence  of  vagina  and  complete  atrophy  of  cellular 
tissue  in  the  genital  organs ;  at  the  same  time  the  pelvis  approximated 
to  the  male  type,  and,  in  place  of  the  pubic  arch,  the  rami  of  the 
pubes  and  ischia  appeared  as  though  they  were  in  contact  at  the  site 
usually  occupied  by  the  vagina. 

In  fetal  life,  the  female  sacrum,  owing  to  the  small  size  of  the 
vertebrae,  is  narrower  than  in  the  male.  Subsequently  the  more  rapid 
growth  of  the  alae  becomes  the  cause  of  the  increased  width  which 
characterizes  the  sacrum  of  the  female  at  maturity.  The  larger  cir- 
cumference of  the  brim  in  the  female  is  due  partly  to  this  difference 

*  Duncan,  Researches  in  Obstetrics. 

f  Vide  Tilt,  Uterine  and  Ovarian  Inflammation,  p.  C3. 


MECHANISM   OF   LABOR. 


157 


in  the  width  of  the  sacrum  and  partly  to  the  greater  length  of  the 
linea  innominata. 

The  Soft  Parts  of  the  Pelvis.— Prefatory  to  the  history  of  the  im- 
pregnated ovum,  we  have  already  considered  the  more  important  pel- 
vic viscera  concerned  in  generation  and  parturition.     In  studying  the 

mechanism  of  labor,  it  is,  however,  necessary  in  addition  to  recall 

1.  The  soft  tissues  which  encroach   upon   the  pelvic  space;   2.  The 


AORTA. 


VENA  CAVA 


PSOAS  MUSCLE 


PRIMUrVF   ILIAC 

VEIN, 


EXTERNAL  ILIAC  VEIN 
ILIAC  MUSCLE 


PRiMlTlVi 
lUAO. 


EXTERNAL 
ILIAC. 

INTERNAL  ILIAC 


Fig.  88.— Pelvis  covered  with  the  soft  parts,  with  removal  of  bladder,  uterus,  and  rectum. 

structures  which   close  in  the  openings  of  the  pelvis,  and  convert  it 
into  a  basin-like  cavity. 

1.  The  diameters  of  the  brim  are  diminished  somewhat  by  the 
ilio-psoae  muscles.  The  iliac  muscles  proper  occupy  the  entire  surface 
of  the  internal  iliac  fossa?.  The  fibers  converge  below,  and,  passing 
beneath  Poupart's  ligament,  become  united  to  the  borders  of  the  psoas 
muscle.  The  pelvic  portion  affords  a  soft  cushion  for  the  support  of 
the  gravid  uterus.     The  great  psoje  muscles  fill  out  the  spaces  upon 


158 


LABOR. 


the  sides  of  the  promontory.  They  take  their  origin  from  the  lateral 
surfaces  of  the  bodies  and  transverse  processes  of  the  four  upper  him- 
bar  and  tlie  last  dorsal  vertebrse.  They  cross  the  pelvis  parallel  to  the 
linea  innominata,  which,  hovrever,  they  slightly  overlap.  They  taper 
below,  and,  passing  beneath  the  femoral  arch,  terminate  in  a  tendon, 
which  is  inserted  into  the  small  trochanter.  These  two  muscles  flex 
the  thighs  upon  the  abdomen.  The  iliac  muscle  likewise  acts  as  an 
abductor,  and  the  psoas  serves  to  flex  the  pelvis  upon  the  spinal  col- 
umn. The  ilio-psoa3  muscles  diminish  the  transverse  diameter  nearly 
a  half-inch,  so  that  the  latter  becomes  very  nearly  equal  in  length  to 
the  oblique  diameters.  When  the  limbs  are  extended  and  the  muscles 
are  rendered  tense,  the  influence  they  exert  in  lessening  the  pelvic 
space  is  somewhat  greater  than  when  they  are  relaxed  by  flexing  the 
legs  upon  the  thighs. 

The  large  arteries  and  veins  at  the  pelvic  brim  do  not  undergo  com- 
pression during  labor  under  normal  conditions.     When,  however,  con- 


SACRUM. 


FORMIS  M. 


Fig.  89.— Section  of  pelvis,  showing  the  pjTiform  muscles.    (Tarnier  et  Chantreuil.) 

siderable  disproportion  exists  between  the  pelvis  and  the  child's  head, 
the  effects  of  pressure  are  sometimes  manifested  in  the  swelling  of  all 
the  soft  tissues  within  the  pelvic  cavity— a  swelling  which,  in  turn, 
enhances  the  difficulties  of  delivery. 

2.  The  open  spaces  of  the  pelvis,  which  are  closed  in  by  soft 
parts,  are  the  great  sciatic  notches,  the  obturator  foramina,  and  the 
pelvic  outlet. 

The  closure  of  the  sacro-sciatic  notches  is  effected  by  the  pyriformis 
muscles.  The  pyriformis  muscle  has  a  triangular  shape.  Its  base 
presents  a  series  of  digitations  which  are  inserted  upon  the  lateral 
portions  of  the  anterior  surface  of  the  sacrum,  along  the  outer  borders 
of  the  four  lower  sacral  foramina  and  the  upper  portion  of  the  sacro- 


MECHANISM   OF   LABOR. 


159 


SACRO-SCIATI 
I.IG. 


LARGE  SAC  RC -SCIATIC  LIG. 


PUBIS, 


sciatic  ligament.  It  then  crosses  the  large  sciatic  foramen,  and, 
passing  outward,  terminates  in  a  tendon,  which  is  inserted  into  the 
large  trochanter. 

The  obturator  foramen  is  covered  by  the  internal  obturator  mus- 
cle. The  latter  is  attached  to  the  quadrilateral  surface  which  corre- 
sponds to  the  cotyloid  cavity,  to  the  circumference  of  the  foramen,  and 
to  the  inner  surface  of  the  obturator  membrane.  Its  fibers  converge 
to  form  a  tendon,  which  passes 
through  the  lesser  sciatic  fora- 
men, and  thence  is  directed 
downward  and  backward  to 
the  digital  cavity  of  the  great 
trochanter. 

Owing  to  their  tenuity, 
and  to  the  fact  that  they 
fqrm  distensible  coverings  to 
spaces  limited  only  by  elastic 
tissues,  neither  the  pyriform 
nor  the  obturator  muscles  ap- 
preciably affect  the  dimen- 
sions of  the  pelvic  cavity. 

The  outlet  of  the  pelvis 
is  closed  by  a  succession  of 
layers,  which  together  consti- 
tute the  perineal  or  pelvic 
floor.  These  layers,  passing 
from  Avithout  inward,  consist 
respectively  of  the  external  cutaneous  tissue,  the  muscular  layers  with 
their  associated  aponeuroses,  the  subperitoneal  cellular  tissue,  and  the 
peritonaeum. 

The  most  important  structure  which  enters  into  the  formation  of 
the  perineal  floor  is  the  levator-ani  muscle.  This  muscle  is  attached 
above  partly  to  the  horizontal  rami  of  the  pubes,  about  an  inch  and  a 
half  below  the  upper  border  of  the  rami,  and  partly  to  the  tendinous  arch 
of  the  pelvic  fascia,  which  is  situated  about  two  inches  below  the  ilio- 
pectineal  line,  stretching  from  the  inner  border  of  the  pubes  to  the 
spines  of  the  ischia.  The  pubic  portion  consists  of  separate  bands, 
about  two  fingers  in  width.  These  sweep  nearly  horizontally  back- 
ward, and  are  united  behind  the  rectum,  which  they  encircle  like  a 
collar.  The  anterior  insertions  are  about  an  inch  apart  from  one 
another.  The  fibers  attached  to  the  tendinous  arch  do  not  possess  a 
uniform  arrangement.  Passing  from  before  backward,  we  have  first  a 
band  a  few  lines  in  width,  which  crosses  the  pubic  bundles  and 
descends  to  the  recto- vaginal  septum  ;  next,  large  bundles  descend  from 
the  two  sides  and  meet  behind  the  rectum ;   then  follows  a  smaller 


INTERNAL 
OBTURATOR 


Fig.  90.— Section  of  pelvis,  showing  the  internal 
obturator  muscle.    (Tarnier  et  Chantreuil.) 


160 


LABOR. 


median  portion,  whose  fibers  are  united  by  a  tendinous  raphe  in  front 
of  the  coccyx,  while  posteriorly  a  narrow  bundle  is  fastened  by  a 
tendon  to  the  fourth  coccygeal  vertebra.  The  arrangement  of  the 
muscular  fibers  is  best  seen  from  the  side,  as  in  Fig.  93,  where  the 
ischium  has  been  removed. 

Tlie  margins  which  border  the  rectum  and  vagina  are  thicker  than 
the  rest  of  the  levator.  They  are  closely  attached  to  those  organs  by 
strong  connective  tissue.     They  cross  the  vagina  beneath  the  bulbs  of 


Fig.  91.— The  levator-ani  muscle  as  seen  from  above,  with  the  tendinous  arch  which  spans  the 
obturator  muscle.    (Dickinson.) 


the  vestibules  ;  the  rectal  crossing  is  on  a  level  with  the  upper  fibers  of 
the  external  sphincter.  The  contraction  of  the  muscle  draws  the 
rectum  and  vagina  toward  the  symphysis.  The  average  power  exerted 
is  estimated  by  Dickinson*  at  ten  pounds,  rising  in  certain  cases  to 
twenty-seven  pounds. 

The  levator  measures  from  |  to  f  of  an  inch  in  thickness.  It  be- 
comes, however,  hypertrophied  during  pregnancy. 

The  muscular  floor  of  the  pelvis  is  rendered  complete  by  the  coccy- 
geus  muscle,  situated  between  the  levator  and  the  pyriformis,  and  in 
front  of  the  small  sciatic  ligament.     The  base  is  attached  to  the  sides 

*  Dickinson,  Studies  of  the  Levator  Ani  Muscle,  Am.  Jour.  Obstetrics,  Sept., 
1889,  p.  909.  To  this  article  I  am  indebted  for  the  changes  made  in  the  present 
text. 


MECHANISM   OF   LABOR. 


161 


of  the  coccyx  and  the  lower  extremity  of  the  sacrum  ;  the  insertion  of 
the  apex  is  at  the  spine  of  the  ischium.  In  caudate  animals  the  coccv- 
geus  is  strongly  developed,  and  enables  them  to  move  the  tail  laterally. 
The  upper  surface  of  the  levator-ani  and  coccygeal  muscles  is  con- 
cave. The  muscles  themselves  are  flattened,  and  alone  are  capable  of 
affording  but  feeble  support  to  the  superimposed   viscera.     They  are, 


Fig.  92.— The  levator  (L)  seen  from  the  side  when  the  ischium  is  removed.  The  lower  bundles 
are  the  strong  and  heavy  ones.  The  sphincter  ani  is  shown  surrounding  the  anus  and  the 
coccygeus  is  faintly  indicated.    (Redrawn  from  Luschka  by  Dickinson.) 

however,  above  closely  attached  to  the  strong  tissues  of  the  internal 
pelvic  fascia,  which  possess  the  qualities  of  elasticity  and  toughness. 

The  internal  pelvic  fascia  is  attached  to  the  upper  border  of  the 
superior  strait,  where  it  meets  the  fascia  which  lines  the  iliac  fossae 
and  the  transverse  fascia  of  the  abdominal  walls.  It  covers  the  pyri- 
formis  and  the  upper  half  of  the  obturator  muscles.  In  front  it  de- 
scends from  the  symphysis  to  the  neck  of  the  bladder,  and  forms  the 
pubo-vesical  ligament.  From  the  linea  terminalis  to  the  arcus  ten- 
11 


Hj2 


LABOR. 


dineus  the  fascia  upon  the  side  walls  is  firmly  attached  to  the  perios- 
teum. The  tendinous  arch  marks  the  line  at  which  the  fascia  leaves 
the  pelvic  walls  to  form  the  inner  lining  of  the  levator  and  coccygeal 

muscles. 

The  upper  surface  of  the  internal  pelvic  fascia  is  covered  by  the 
peritonfeiim,  to  which  it  is  united  by  loose  connective  tissue. 

The  fascial  coverings  beneath  the  levator-ani  muscle  are  divided 
into  a  posterior  and  anterior  portion  by  a  line  drawn  between  the  two 
ischia. 

The  posterior  portion  consists  of  a  single  layer.  It  starts  from  the 
sacro-sciatic  ligaments  and  the  tuberosities  of  the  ischia;   thence  it 

mounts  upward  over 
the  inner  surfaces  of 
the  ischia  and  the  ob- 
turator internus  muscle 
to  the  tendinous  arch, 
which  it  contributes  to 
form,  and  from  the 
tendinous  arch  is  re- 
flected at  an  acute 
angle  over  the  inferior 
surface  of  the  levator- 
ani  muscle.  The  space 
thus  limited  between 
the  side  walls  of  the 
pelvis  and  the  levator 
ani  is  termed  the  ischio- 
rectal excavation. 

The  anterior  por- 
tion, or  perineal  fascia 
proper,  fills  the  space 
between  the  bis-ischiatic  line  and  the  arch  of  the  pubes.  It  is  composed 
of  three  layers,  as  follows  :  1.  The  deep  perineal  fascia,  which  covers 
the  lower  surface  of  the  levator  ani ;  2.  The  median  perineal  fascia, 
separated  from  the  former  by  a  narrow  interval,  and  inclosing  the 
pudic  vessels  and  nerves;  3.  The  superficial  perineal  fascia  which 
forms,  with  the  median  layer,  a  shallow  compartment  in  which  are  lodged 
the  superficial  muscles  of  the  perinaeum,  the  bulbs  of  the  vagina,  the 
vulvo-vaginal  glands,  and  the  rami  of  the  clitoris.  Each  one  of  these 
organs,  except  the  latter,  is,  moreover,  enveloped  in  a  special  sheath, 
derived  from  prolongations  of  the  upper  surface  of  the  aponeurosis. 

The  superficial  perineal  muscles  are  of  slight  obstetrical  importance. 
They  are  the  constrictor  vaginse,  the  ischio-cavernosi,  and  the  trans- 
versi  perin^ei. 

The  constrictor  vagina  consists  of  two  small  lateral  muscles,  situ- 


THREE  LAYERS  OF 
THE  PERINEAL  FASCIA 


Fig.  93.— Antero-posterior  section  of  the  perineal  floor. 
(Tarnier  et  ChantreuH.) 


MECHANISM   OF   LABOR. 


163 


ated  upon  the  outer  sides  of  the  vestibular  bulbs,  and  surrounding  the 
vulvar  orifice.  Posteriorly  the  extremities  of  the  main  muscle  start 
from  the  perineal  fascia  at  a  point  nearly  midway  between  the  sphinc- 
ter ani  and  the  ischia,  while  a  small  bundle  only  is  connected  with  the 
sphincter  ani  itself.*  x\bove,  the  convergent  ends  separate  into  a 
superficial  and  deep  portion.  The  superficial  portions  terminate  in  a 
tendon  which  unites  them  together  above  the  dorsal  vein  of  the  clito- 
ris ;  the  deep  portions  pass  between  the  upper  ends  of  the  bulbs  and 
the  clitoris,  and  are  likewise  united  by  an  aponeurosis. 

The  action  of  the  muscle  consists  chiefly  in  compressing  the  veins 
crossed  by  its  tendon,  and  in  thus  enhancing  the  turgidity  of  the  erectile 


CLITORIS. 


.^V 


URETHRA. 


CONSTRICTOR 

CUNNI  M. 


TRANSVERSUS    '   PERINAEI 


Fig.  94.— Muscles  of  the  periuseuai.    (Henle.) 


apparatiis.     It  is  in  no  sense  a  sphincter  muscle,  though,  by  pressing 
the  turgid  bulbs  inward,  it  may  narrow  the  vestibule  of  the  vagina. 

The  ischio-cavernosi  muscles  form  a  fibro-muscular  sheath  about  the 
crura  of  the  clitoris.     They  are  united  together  above  by  an  aponeuro- 
sis which  crosses  the  posterior  extremity  of  the  body  of  the  clitoris. 
During  sexual  excitement  these  muscles  are  capable  not  only  of  com- 
*  LuscHKA,  Anatomie  des  menschlichen  Beckens,  p.  399. 


164 


LABOR. 


I^ressing  the  crura,  thereby  forcing  the  blood  toward  the  body  of  the 
clitoris,  but,  through  the  pressure  exerted  by  the  ajjoneurosis  upou  the 
dorsal  vein,  they  help  to  retard  the  return  of  the  blood  from  the  turges- 
cent  organ. 

The  transversi  perini»i  muscles  are  small,  triangular,  flattened 
muscles,  which  j^ass  from  the  inner  sides  of  the  ischia,  underneath  the 
constrictor  muscle,  to  the  sides  of  the  vagina  and  rectum.  AVhen  the 
perinajum  is  lacerated,  these  muscles  tend  to  produce  gaping  of  the 
wound,  and  to  interfere  with  union  by  first  intention. 

A  mere  enumeration,  such  as  has  been  given,  of  the  thin,  flat,  mus- 
cular and  aponeurotic  structures  of  the  pelvic  floor  affords,  however, 
a  very  incomplete  idea  of  the  true  anatomy  of  the  lower  portion  of  the 


Fir;.  95.— Tlif  partiirietit  canal.     iHoilj;*'  i 

parturient  canal.  Both  as  regards  form  and  function,  the  role  of  the 
connective  tissue  which  fills  out  all  the  available  interstices  between 
the  different  organs,  the  different  muscular  groups  and  the  bony  walls, 
is  of  the  highest  importance.  It  is  to  this  tissue  that  the  perineal 
body  occupying  the  space  between  the  vagina  and  rectum  owes  its  ex- 
traordinary distensibility.  In  a  sagittal  section,  the  perineal  body  has 
usually  very  nearly  a  quadrangular  shape.*  Laterally  it  spreads  out 
to  the  rami  and  the  tuberosities  of  the  ischia.  In  height  it  extends 
upward  nearly  one  half  the  length  of  the  vagina.  Between  the  border 
of  the  anus  and  the  posterior  commissure  of  the  vulva,  the  external 
portion,  which  forms  the  base  of  the  triangle,  measures  on  the  average 

*  Foster,  P.  P.,  Anatomy  of  the  Uterus  and  its  Surroundings,    \m.  Jour,  of 
Obstet.,  January,  1880. 


MECHANISM  OF  LABOR. 


Un") 


an  inch  in  length.  When  the  head  of  the  child,  during  labor,  de- 
scends below  the  level  of  the  bony  walls,  it  bulges  the  perinfeum  and 
stretches  it  from  four  to  five  inches  in  the  antero-posterior  direction. 
Both  the  length  and  degree  of  curvature  of  the  pelvic  canal  are  there- 
by increased,  the  soft  parts  posterior  to  the  vulva  forming  a  gutter- 
like extension,  the  axis  of  which  is  continuous  with  that  of  the  pelvis. 

The  Head  of  the  Fcetus  at  Term. 

The  head  is  the  part  which  presents  the  greatest  mechanical  diffi- 
culties in  the  passage  of  the  foetus  through  the  parturient  canal.  It 
is  therefore  important  to  become  familiar  with  its  shape,  its  diameters, 
and  the  modification  it  undergoes  during  labor. 

In  studying  the  fetal  head  we  distinguish  the  face  and  the  cranium. 

The  face  is  of  little  importance  in  normal  labors.  It  may,  how- 
ever, be  here  incidentally  noted,  what  is  sometimes  of  consequence  in 


Fig.  yii.— Lateral  view  of  fetal 
skull.    (Hodge.) 


Fi<i.  97.     hetal  head,  as  seen 
trom  above.     (Hodge.) 


extreme  degrees  of  pelvic  contraction,  that  the  distance  (two  and  a 
half  inches)  between  the  malar  bones  possesses  but  a  slight  degree  of 
reducibility. 

In  the  cranium  Ave  distinguish  again  between  the  upper  compressi- 
ble portion  or  vault  and  the  lower  incompressible  portion  or  base  of 
the  skull.  The  vault  is  composed  of  the  frontal  and  parietal  bones 
and  the  squamous  portions  of  the  temporal  and  occipital  bones.  The 
base  is  formed  by  the  union  of  the  ethmoid,  the  sphenoid,  the  petrous 
portion  of  the  temporal  bones,  and  the  basilar  portion  of  the  occipital 
bone. 

The  Sutures  and  Fontanelles.— The  flat  bones  which  form  the  vault 
are  thin  and  imperfectly  ossified,  consisting,  indeed,  of  little  more  than 
the  diploe.  Instead  of  union  by  serrated  osseous  borders,  they  are 
held  in  their  relative  positions  by  the  periosteum  and  dura  mater, 
which  come  into  contact  with  one  another  and  form  membranous  com- 
missures between  the  bones.  Where  more  than  two  bones  meet  at  a 
given  point,  the  ossification  is  apt  to  be  incomplete,  and  spaces  are  left, 
covered  only  by  membranes  termed  fontanelles. 

The  sutures,  to  which  it  will  be  found  necessary  to  make  constant 
reference,  are  the  following  :    The  frontal  suture,  situated  between  the 


IGG 


LABOR. 


ununited  halves  of  the  frontal  bone ;  tlie  coronal  suture,  between  the 
frontal  and  parietal  bones ;  the  sagittal  suture,  where  the  parietal 
bones  meet  at  the  top  of  the  cranium  ;  the  lambda  suture,  so  called 
from  its  resemblance  to  the  Greek  letter  of  that  name,  between  the 
triano-ular  portion  of  the  occipital  and  the  posterior  borders  of  the 
parietal  bones. 

At  the  point  of  intersection  of  the  frontal,  the  sagittal,  and  the 
coronal  sutures  the  incomplete  ossification  of  the  frontal  and  parietal 
bones  leaves  a  large  open  space  of  a  rhomboidal  shape,  termed  the  an- 
terior or  large  fontanelle,  or  sometimes  simply  the  bregma.  Of  the 
four  sides,  the  anterior  are  longer,  often  extending  for  some  distance 
between  the  bones  of  the  os  frontis. 

The  posterior  or  small  fontanelle  is  situated  at  the  junction  of 
the  sagittal  and  lambda  sutures.  It  is  formed  at  the  meeting  of  three 
bones,  viz.,  the  two  parietal  and  the  occipital,  and  possesses  a  triangu- 
lar shape.  In  very  many  cases  the  ossification  of  the  bones  is  complete 
at  the  time  of  delivery.  Its  site  then  is  indicated  by  the  angle  formed 
by  the  posterior  borders  of  the  parietal  bones,  beneath  which,  as  a 
consequence  of  labor,  the  occipital  bone  is  usually  found  depressed. 

Budin  has  recently  demonstrated  that  the  squamous  or  triangular 
portion  is  attached  to  the  basilar  portion  of  the  occipital  bone  by  means 
of  a  band  of  cartilaginous  and  fibrous  tissue.  A  sort  of  hinge-joint  is 
thus  formed,  which  permits  veritable  movements  of  flexion  and  exten- 
sion to  take  place.* 

The  flexibility  of  the  cranial  bones,  the  sutures,  the  fontanelles, 
and  the  fibro-cartilaginous  bands  of  union,  together  enable  very  con- 
siderable changes  to  take  place  in  the  diameters  of  the  fetal  head 
during  the  progress  of  labor. 

The  Diameters  of  the  Fetal  Head.— The  diameters  of  the  child's 
head  are  a  series  of  imaginary  lines  extending  between  fixed  points, 
selected  so  as  to  indicate  the  dimensions  of  the  largest  segments  which, 
in  the  different  positions  and  presentations,  engage  in  the  pelvic  canal. 
We  distinguish  diameters  running  in  the  antero-posterior,  the  trans- 
verse, and  the  vertical  directions.! 

The  antero-posterior  diameters  are :  1.  The  occipito-mental ;  2.  The 
occipito-frontal ;  3.  The  sub-occipito-bregmatic. 

The  occipito-mental  diameter  extends  from  the  highest  point  of 
the  occiput  to  the  chin ;  J  the  occipito-frontal,  from  the  occiput  to 
the  root  of  the  nose ;  the  sub-occipito-bregmatic,  from  the  junction 

*  BuDiN^  De  la  Tete  du  Foetus,  p.  73. 

t  The  points  of  departure  of  the  following  diameters  have  been  adopted  from 
Budm's  excellent  monograph,  already  quoted. 

t  The  occipito-mental  diameter  is  usually  referred  to  as  the  longest  one  of  the 
head.  According  to  Budin,  the  true  maximum  diameter  is  situated  between  the 
chm  and  a  variable  point  in  the  line  of  the  sagittal  suture  above  the  occiput. 


MECHANISM   OF   LABOR. 


167 


oithe  occiput  with  the  neck  to  the  point  of  intersection  in  the  large 
fontanelle  of  the  coronal  and  sagittal  sutures. 

The  transverse  diameters  are :  1.  The  bi-parietal ;  2.  The  hi-tem- 
poral ;  3.  The  bi-mastoid. 

The  bi-parietal  diameter  stretches  between  the  two  bosses  or  pro- 
tuberances of  the  parietal  bones ;  the  hi- temporal,  between  the  extremi- 


OCCIPITO  MENTAL "> 


F  RONTO  MENTAL. 


OCCIPITOFRONTAL. 


SUB  QCCIPITO  BREGMATIC 

'"  JFrVICO  BREGMATIC. 
Fig.  98.— Antero-posterior  ami  vt-rtical  diameters  of  the  fetal  head.    (Tarnier  et  ChantreuiL) 

ties  of  the  coronal  sutures ;  the  bi-mastoid,  between  the  mastoid  pro- 
cesses at  the  base  of  the  skull. 

The  vertical  diameters  are  ;  1.  The  fronto-mental ;  2.  The  cervico- 
bregmatic. 

The  fronto-mental  diameter  extends  from  the  top  of  the  forehead 
to  the  point  of  the  chin  ;  the  cervico-bregmatic,  from  the  middle  of 
the  large  fontanelle  to  the  upper  portion  of  the  neck  near  the  larynx. 

In  furnishing  standard  measurements  of  the  foregoing  diameters 
it  is  of  course  understood  that  no  two  heads  present  precisely  the  same 
dimensions.  As  a  rule,  as  shown  by  Sir  J.  Y.  Simpson,  the  heads  of 
boys  are  larger  than  those  of  girls.  In  selecting  type-cases  it  will  be  re- 
membered too,  that,  owing  to  the  plasticity  of  the  head,  in  none  are 
the  diameters  completely  normal  immediately  after  the  transit  through 
the  generative  passages.  Unless,  therefore,  the  child  is  delivered  by 
Cesarean  section,  sufficient  time  should  be  allowed  to  elapse  after  de- 
livery before  the  measurements  are  made,  to  permit  the  head  to  return 
to  its  natural  shape.  Again,  as  in  the  measurements  of  the  pelvis,  the 
figures  selected  to  represent  the  normal  average  should  be  such  as 
admit  of  convenient  recollection. 

DIAMETERS    OF    FETAL    HEAD.* 

Occipito-mental  diameter ^^  inches. 

Occipito-f  rental        '*  ** 

*  The  diameters  given  are  based  upon  the  table  in  Tarnier  and  Chantreuil,  which 
were  averaged  from  measurements  taken  with  great  precision  in  forty-four  cases. 


■|/>D  LABOR. 

Sub-occipito-bregmatic  diameter 3|  inches. 

Bi-parietal  "       3J 

Bi-temporal  "       3J 

Bi-mastoid  "       3 

Fronto-raental  "       3J 

Cervico-bregmatic  "       3  J 

The  circumference  of  the  head,  from  the  chin  to  the  vertex,  using 
the  latter  term  to  express  the  highest  part  of  the  skull,  without  refer- 
ence to  any  fixed  anatomical  point,  is  about  fourteen  and  three  quar- 
ters inches.  The  circumference  at  the  sub-occipito-bregmatic  diameter 
is  but  thirteen  inches. 

The  Articulation  of  the  Head  with  the  Spinal  Column.— The  move- 
ments of  the  occiput  upon  the  atlas  are  extremely  limited,  those  of 
extension  and  flexion,  which  the  head  executes  so  readily,  taking  place 
for  the  most  part  in  the  articulations  of  the  cervical  vertebrae.  Move- 
ments of  rotation  are  performed  at  the  articulation  between  the  axis 
and  the  atlas  In  practice,  the  head  can  not  be  turned  with  safety  to 
either  side  beyond  a  quarter  of  a  circle,  though,  when  rotation  is  per- 
formed slowly  after  delivery,  it  may  sometimes  be  carried  to  such  an 
extent  as  to  enable  the  face  to  look  directly  backward.  The  insertion 
of  the  spinal  column  at  a  point  nearer  to  the  occipital  than  the  frontal 
extremity  of  the  child's  head  is  of  supreme  importance  in  the  further- 
ance of  the  mechanical  processes  of  labor.  It  converts  the  head  into 
a  lever,  consisting  of  two  unequal  portions.  When  the  head,  there- 
fore, encounters  circular  resistance  in  passing  thi'ough  the  obstetric 
canal,  pressure  transmitted  through  the  spinal  column  causes  the  de- 
scent of  the  occipital  short  end  of  the  lever ;  while  the  pressure  upon 
the  forehead  from  the  side  walls  flexes  the  chin  upon  the  thorax,  the 
degree  of  flexion  depending  upon  the  size  of  the  canal  through  which 
the  transit  is  made. 


CHAPTER   IX. 

MECHANISM  OF  LABOR.— (Continued.) 

Presentations :  natural,  unnatural,  normal.— Vertex  presentations :  frequency,  posi- 
tions.—Manner  m  which  head  enters  pelvis.— Positions,  normal  mechanism  of 
labor.— Descent  and  flexion.— Rotation.— Extension.— External  rotation.— Ex- 
pulsion of  the  trunk. — Abnormal  mechanism  (vertex  presentations). — Mechanism 
of  oecipito-posterior  positions.— Configuration  of  the  head  in  vertex  presenta- 
tions.—Molding.— Scalp-tumor. — Diagnosis  of  vertex  presentations. 

The  mechanism  of  labor— -i.  e.,  the  manner  in  which  the  foetus 
passes  through  the  parturient  canal— varies  with  the  presentation. 
The  presentations  are  classified,  in  the  first  place,  with  reference 


MECHANISM  OF   LABOR.  ^09 

to  the  position  of  the  fcetus  in  relation  to  the  axis  of  the  uterus.  In 
cases  where  the  long  diameter  of  the  fretus  coincides  with  that  of  the 
uterus,  we  have  further  to  distinguish  presentations  of  the  head  and 
presentations  of  the  pelvic  extremity. 

Head  or  cephalic  presentations  comprise  those  of  the  vertex,  i.  e., 
the  portion  lying  between  the  two  fontanelles,  the  brow,  and  the  Jace^ 

Pelvic  presentations  oifer  two  varieties,  viz.,  breech  presentations 
and  foot  presentations. 

When  the  long  diameter  of  the  foetus  crosses  the  axis  of  the  uterus, 
there  is  produced  a  transverse,  or,  after  the  operation  of  uterine  con- 
tractions, a  shoulder  presentation. 

Vei-tex,  face,  and  pelvic  presentations  are  included  in  the  category 
of  natural  labors.  Brow  and  shoulder  presentations  are  termed  unnat- 
ural, as,  with  few  exceptions,  they  are  not  terminable  except  by  the 
resources  of  the  obstetric  art. 

Vertex  presentations  alone  are  to  be  regarded  as  normal,  as  they 
only  realize  the  mechanical  conditions  compatible  with  the  highest 
degree  of  safety  to  both  mother  and  child. 

In  the  following  pages  it  is  purposed  to  associate  with  the  descrip- 
tions of  the  mechanism  of  labor,  in  the  various  presentations  and  posi- 
tions, an  account  of  the  means  of  diagnosis  and  the  treatment  suited 
to  the  special  cases  under  consideration,  instead  of  placing  diagnosis, 
mechanism,  and  treatment  in  chapters  distinct  from  one  another. 
The  writer  believes,  from  long  experience  in  teaching,  that  what  is  thus 
sacrificed  in  the  way  of  systematic  completeness  is  more  than  compen- 
sated by  the  clinical  advantage  of  keeping  in  close  proximity  the  prin- 
ciples of  obstetric  art  and  the  rules  of  practice  directly  deducible  from 
them. 

Precedence  of  description  is  given  to  the  vertex  presentation  as 
representing  the  normal  type  of  labor. 

,     A'ertex  Presentations. 

In  93,871  births,  collected  from  private  practice,  Spiegelberg  found 
that  in  over  ninety-seven  per  cent  the  cranial  vault  presented,*  The 
back  of  the  child  in  utero  is  directed  in  about  seventy  per  cent  of 
cases  to  the  left,  and  in  thirty  per  cent  to  the  right,  side  of  the  mother. 
The  fronto-occipital  diameter  of  the  head  measures  four  inches  and 
a  half.  The  diameters  of  the  pelvic  brim,  after  deducting  the  soft 
parts,  are  nearly  as  follows  : 

Transverse  diameter  of  brim 4f  to  5  inches. 

Oblique  "  "        4f  to  5  inches. 

Antero-posterior  diameter  of  brim  (minimum  diameter 

about  one  third  inch  below  the  crista  pubis) 4  inches. 

*  Spiegelberg,  Lehrbuch  der  Geburtshiilfc,  p.  148. 


170 


LABOR. 


Thus  it  will  be  seen  that  the  fronto-occipital  diameter  of  the  head 
may,  at  the  brim,  enter  the  pelvis  without  meeting  with  any  special 
resistance  in  either  the  transverse  or  oblique  diameters.  In  the  conju- 
gate diameter,  on  the  contrary,  this  is  not  possible.  Transverse  posi- 
tions, where  the  conditions  are  normal,  are  of  very  exceptional  occur- 
rence, though  they  form  the  rule  in  flattened  pelves.  Tarnier  * 
suggests  that  this  infrequency  is  jDartially  explicable  on  mechanical 
grounds.  The  long  transverse  diameter  of  the  pelvis,  he  says,  is, 
owing  to  the  projection  of  the  promontory,  situated  in  a  line  consid- 
erably posterior  to  the  point  at  which  the  sagittal  suture  normally 
meets  the  conjugate.  When  the  head,  therefore,  enters  the  pelvis  in  a 
transverse  direction  with  both  parietal  bones  upon  the  same  plane,  the 
fronto-occipital  diameter  corresponds  to  a  shortened  chord  subtending 
two  points  of  the  pelvic  ring  in  front  of  the  anatomical  transverse 
diameter ;  in  point  of  fact,  therefore,  the  latter,  at  the  site  of  engage- 
ment, is  less  than  either  of  the  oblique  diameters.  In  flattened  j^elves 
this  difficulty  does  not  exist,  as,  in  place  of  both  parietal  bones  entering 
upon  the  same  level,  the  posterior  is  turned  toward  the  corresponding 
shoulder,  the  anterior  dipping  obliquely  into  the  brim  (lateral  obliquity 
of  Naegele),  an  arrangement  by  which  the  long  diameter  of  the  head 
is  brought  into  correspondence  with  the  long  diameter  of  the  pelvis. 

At  the  time  when  the  sagittal  suture  is  accessible,  and  it  is  possible 
to  observe  with  correctness,  the  antero-posterior  diameter  of  the  head 
is  found  to  approximate  to  one  or  the  other  of  the  pelvic  oblique  diam- 
eters. 

It  is  customary  to  classify  the  positions  of  the  head  with  reference 
to  the  direction  of  the  occiput.  Most  English  authorities  admit  four 
varieties,  viz. : 

The  right  occipito-anterior  (occii>ito-dextra  anterior,  0.  D.  A.), 
the  right  occipito-posterior  (occipit*dextra  posterior,  0.  D.  P.),  the 
left  occipito-anterior  (occipito-lfeva  anterior,  0.  L.  A.),  the  left  oc- 
cipito-posterior (occipito-lgeva  posterior,  0.  L.  P.). 

Naegele  first  called  attention  to  the  fact  that  the  head  approximates, 
in  an  overwhelming  proportion  of  cases,  to  the  right  oblique  diameter ; 
that,  therefore,  when  directed  to  the  left,  the  occiput  is  turned  to  the 
cotyloid  cavity,  and,  when  directed  to  the  right,  it  looks  toward  the 
sacro-iliac  synchondrosis.  This  peculiarity  probably  results  from  the 
fact  that  the  uterus  is  usually  rotated  in  such  a  way  upon  the  spine 
that  the  right  side  inclines  obliquely  backward,  while  the  left  side  is 
turned  somewhat  to  the  front. 

Naegele's  observation  is  undoubtedly  correct  as  regards  the  position 
of  the  head  after  labor  has  actually  begun.     Sutugin,f  however,  main- 

*  Tarnier  et  Chantreuil,  Traite  de  I'art  des  accouchements,  p.  465. 
t  SuTUGiN,  Beitrage  zum  Mechanismus  der  Geburt  bei  Schadellagen,  KHnischer 
Vortrage,  No  310. 


MECHANISM   OF   LABOR. 


171 


tains  that  when  the  patient  is  examined  in  the  recumbent  position  during 
pregnancy  abdominal  palpation  sliovvs  that,  as  a  rule,  the  back, of  the 
child,  whether  situated  to  the  right  or  the  left  of  the  vertebral  column, 
is  turned  somewhat  posteriorly. 

At  the  beginning  of  labor  the  head,  surrounded  by  the  lower  seg- 
ment of  the  uterus,  is  commonly  found  at  the  brim  or  resting  upon 
;in  iliac  fossa  in  multiparae,  and  below  the  brim,  Avithin  the  pelvic 
cavity,  in  primiparae.  The  direction  of  the  head,  as  regards  its  vertical 
axis,  depends  upon  the  degi-ee  of  resistance  afforded  by  the  contigu- 
ous uterine  tissues.  In  the  softened,  relaxed  condition  often  observ- 
able in  multipara  toward  the  close  of  pregnancy,  the  two  fonta- 
nelles  are  not  infrequently  situated  upon  the  same  level.  Where  the 
lower  uterine  walls  are  firm  and  slope  toward  the  os  internum,  the 
weight  of  the  child's  body,  transmitted  through  the  vertebral  column, 
depresses  the  occiput.  At  the  same  time  the  sloping  uterine  walls, 
acting  upon  the  frontal  extremity  of  the  child's  head,  direct  the  chin 
toward  the  thorax,  thus  producing  a  state  of  semi-flexion. 

The  Nokmal  Mechanism  of  Labor. 

The  mechanism  of  labor  in  vertex  presentations  is  usually  described 
as  consisting  of  a  series  of  acts,  termed  respectively  descent,  flexion, 
rotation,  external  restitution,  and  expulsion  of  the  trunk. 

A  familiarity  not  with  the  names  of  the  various  acts,  but  the  things 
the  names  represent,  is  essential  to  the  judicious  prosecution  of  the 
obstetric  art. 

Descent  and  Flexion. — Descent  and  flexion  go  hand  in  hand,  and 
should  be  associated  in  thought  as  they  are  in  reality.  It  is  evident, 
whenever  the  head  encounters  the  resistance  of  the  obstetric  canal, 
the  force  transmitted  through  the  spine  to  the  foramen  magnum  will 
cause  the  descent  of  the  occiput,  and  thus  flexion  will  result.  The 
degree  of  flexion,  however,  is  proportioned  to  the  extent  of  the  action 
of  the  walls  upon  the  frontal  extremity  of  the  head,  and  therefore  is 
variable  in  different  subjects  and  in  different  parts  of  the  canal. 

The  head  enters  the  pelvis  in  the  axis  of  the  brim  with  the  bi- 
parietal  diameter  very  nearly  parallel  to  the  superior  strait.  This  direc- 
tion it  maintains  until  arrested  by  the  curvature  of  the  sacrum  and  by 
the  floor  of  the  pelvis. 

The  descent  of  the  head  through  the  cervix  is  effected  by  the 
pressure  of  the  uterus  during  contraction  upon  its  entire  contents. 
Even  admitting  the  possibility  of  a  certain  amount  of  propulsive 
energy  from  the  uterine  walls  through  the  trunk  of  the  child  to  the 
head,  it  is  necessarily  of  feeble  force,  as  the  flexibility  of  the  spine  and 
the  smoothness  of  tlie  breech  prevent  the  latter  from  finding  a  proper 
point  (Vappui  against  the  vaulted  fundus. 


172 


LABOR. 


In  the  transit  of  the  head  through  the  cervix  the  degree  of  flexion 
is  governed  by  the  amount  of  pressure  exerted  by  the  cervical  ring 
upon  the  frontal  portion.  In  some  instances  this  suffices  to  render 
flexion  complete — i.  e.,  the  chin  sinks  until  arrested  by  contact  with  the 
chest ;  whereas,  as  is  most  often  the  case  in  multipara?,  the  cervix  may 
be  so  softened  and  dilatable  as  to  aifect  but  slightly  the  direction  of 
the  occipi to-frontal  diameter.  Most  frequently  the  maximum  degree 
of  flexion  is  occasioned  by  the  convergence  of  the  walls  of  the  parturi- 
ent canal  at  the  pelvic  outlet.  It  is  well  for  the  beginner  to  keep  con- 
stantly in  mind  that  flexion  is  not  in  any  sense  an  active  movement. 
It  is  always  a  movement  of  accommodation,  the  end  of  which  is  the 
successive  substitution  of  a  shorter  diameter  for  a  previous  longer  one, 
so  soon  as  the  latter  has  encountered  sufficient  resistance  to  arrest 
its  further  progress.  The  mechaYiical  advantages  of  flexion  are  obvious, 
when  we  recall  that  the  average  length  of  the  sub-occipito-bregmatio 


Fig.  99.— Vertex  presentation  ;  child  surrounded  by  aiiuiiutic  Huid.     (Pinard.) 

or  maximum  diameter  of  the  flexed  head  (3f  inches)  is  three  quarteis 
of  an  inch  less  than  the  occipito-frontal  or  maximum  diameter  of  the 
head  when  midway  between  extension  and  flexion.  Again,  the  maxi- 
mum circumference  of  the  flexed  head  (thirteen  inches)  is  1|  inch 
less  than  one  measured  about  the  extremities  of  the  occipito-frontal 
diameter.  These  measurements,  which  are  representative  of  the  natural 
state,  are,  however,  far  from  expressing  the  full  extent  of  the  ditfer- 
ences  which  exist  after  the  plastic  head  has  undergone  the  molding 
processes  incident  to  labor. 


MECHANISxM   OP   LABOR.  -^h^ 

A  further  advantage  of  flexion  is  thus  described  by  Professor  Pajot  ; 
«  The  foetus,  in  its  entirety,  is  to  be  regarded  as  a  broken,  vacillating 
rod,  possessed  of  mobility  at  the  articulation  of  the  head  and  trunk  • 
but  a  solid  thus  disposed  presents  conditions  unfavorable  to  the  trans- 
mission of  a  force  acting  principally  upon  one  of  its  extremities;  it 
follows,  therefore,  that  previous  to  flexion  the  uterine  action,  pressing 
upon  the  pelvic  extremity  to  promote  the  advance  of  the  foetus,  is  lost 
in  great  measure  in  its  passage  from  the  trunk  to  the  head  by  reason 
of  the  mobility  of  the  latter ;  but  the  cephalic  extremity,  once  fixed 
upon  the  thorax,  is  most  advaiitageously  disposed  to  participate  in  the 
impulse  communicated  to  the  general  mass  of  the  foetus."  * 

After  the  head  is  once  released  from  the  environment  of  the  cer- 
vical canal,  a  slight  movement  of  extension  may  follow,  provided  the 
resistance  offered  by  the  vagina  is  less  than  that  of  the  cervix.  In 
many  cases,  as  has  been  stated,  Avhere  dilatation  is  complete  at  the  time 
of  rupture  of  the  membranes,  the  head  may  pass  through  the  cervix 
with  scarcely  any  change  in  its  direction,  flexion  taking  place  first 
when  the  head  encounters  the  resistance  of  the  sloping  pelvic  walls  and 
the  j^erineal  floor. 

Rotation. — The  head,  as  we  have  seen,  follows  the  axis  of  the  su- 
perior strait  until  arrested  by  the  extremity  of  the  sacrum  and  the 
perineal  floor.  As  it  nears  the  latter,  the  curvature  of  the  sacrum  ap- 
proximates the  posterior  Avail  to  the  sagittal  suture.  Upon  vaginal 
examination,  the  finger  comes  in  contact  with  the  anterior  half  of  the 
heail  as  the  presenting  part.  It  is  not,  however,  on  that  account  to 
be  assumed  that  the  head  is  inclined  laterally  toward  the  posterior 
shoulder,  though  the  sensation  produced  deceptively  favors  such  a 
theory,  t 

When  the  head  has  once  reached  the  perineal  floor,  its  further 
progress  is  associated  with  the  most  interesting  of  the  mechanical  acts 
of  labor.  The  occiput,  whether  previously  directed  to  the  anterior  or 
posterior  extremity  of  an  oblique  diameter,  turns  forward  under  the 
arch  of  the  pubes,  until  the  sagittal  suture  occupies  very  nearly  the 
antero-posterior  diameter  of  the  outlet.  The  utility  of  this  movement 
is  obvious.  Owing  to  the  inward  slope  of  the  side  walls  of  the  pelvis, 
the  distance  between  the  ischia  is  but  4^  inches,  and  between  the  spines 
4  inches.  If,  in  forceps  operations,  the  head  is  dragged  through  the 
transverse  diameter  of  the  pelvis  previous  to  rotation,  it  becomes  flat- 
tened and  lengthened  in  the  direction  of  the  trachelo-bregmatic  diam- 

*  Pajot,  Dictionnaire  encyclopedique  des  sciences  medicales,  t.  i,  p.  382,  quoted 
by  Tarnier  et  Chantreuil,  p.  639. 

t  With  the  apparent  obliquity  it  is  probable  that  a  certain  amount  of  real 
obliquity  coexists.  As,  even  in  extreme  flexion,  the  lateral  movements  of  the  head 
are  not  interfered  with,  it  is  hardly  to  be  expected  that  the  head,  when  arrested  at 
the  perineal  floor,  would  continue  to  maintain  a  right  line  with  the  spine. 


174 


LABOR. 


eter,  and  the  child's  life,  and  the  soft  parts  of  the  mother,  are  jeop 
ardized.  When,  however,  rotation  is  completed,  the  bi-parietal  diam- 
eter (3f  inches),  which  is  capable  of  snstaining  a  considerable  degree 
of  lateral  compression,  engages  in  the  transverse  diameter  of  the  pel- 
vis ;  at  the  same  time  the  sub-occipito-bregmatic  engages  in  the  con- 
jugate diameter.  The  latter,  though  measuring  but  3f  inches,  may  be 
extended  to  4^  inches  by  the  pressing  backward  of  the  tip  of  the  coccyx. 
The  conditions  for  the  forward  rotation  of  the  occiput  are — 
1.  Flexion ;  2.  Good  labor-pains ;  3.  A  firm  perinaeum. 
•  In  either  of  the  occipito-anterior  positions  rotation  is  not  diffi- 
cult to  understand.  The  convergent  anterior  inclined  planes  furnish 
smooth  surfaces  upon  which  the  occiput  glides  downward  and  forward 


Fig.  100.— Figure  illustrating  the  mecliauisiu  ut  Ictbor  in  occipito-anterior  deliveries. 
(.After  Sctiultze. ) 


to  the  front.  The  rigid  ischial  spines  direct  the  forehead  to  the  sacro- 
sciatic  ligaments,  which  determine  the  backward  movement  corre- 
sponding to  that  of  the  occiput  in  the  front  part  of  the  pelvis.* 

*  Prof.  Henry  G.  Landis,  in  a  most  ingenious  essay  entitled  How  to  use  the 
Forceps,  argues  that,  practically,  the  pelvis  contains  two  canals,  partially  separate 
at  the  beginning  and  identical  at  their  termination.  The  right  canal  is  the  one  in 
which  the  right  sacro-iliac  articulation  is  found,  and  the  left  the  one  to  which  the 
left  sacro-iliac  articulation  belongs.  These  canals  converge  from  above  down- 
ward, and  are  also  mutually  curved  from  before  backward.  Their  direction  is 
therefore  spiral.  The  caliber  of  each  canal  is  that  of  the  fetal  head  ;  therefore, 
the  head  may  descend  in  either  canal,  and  will  follow  a  spiral  course  in  so  doing. 


MECHANISM   OF  LABOR.  -^^^J^ 

Professor  Pajot  expresses  the  law  which  governs  the  rotation  move- 
ments in  the  following  terms:  "  When  a  solid  body  is  contained  within 
another,  if  the  receptacle  (eontenant)  is  the  seat  of  alternations  of  move- 
ment and  repose,  and  its  surfaces  are  slippery  and  but  slightly  angular, 
the  contained  body  will  tend  increasingly  to  accommodate  its  form 
and  dimensions  to  the  form  and  capacity  of  the  receptacle."  * 

In  occipito-posterior  positions,  the  rotation  of  the  occiput  forward 
is,  at  the  first  glance,  a  puzzling  phenomenon,  as  the  inclined  planes 
of  the  pelvis,  the  ischial  spines,  and  the  law  of  accommodation,  pre- 
viously invoked  by  way  of  explanation,  should  determine  the  rotation 
of  the  occiput  not  to  the  front  but  to  the  sacral  cavity.  The  follow- 
ing experiment  of  Dubois,  however,  throws  considerable  light  upon 
the  principal  conditions  of  success  :  "  In  a  woman  who  had  died  a 
short  time  previous  in  child- bed,  the  uterus,  which  had  remained 
flaccid  and  of  large  size,  was  opened  to  the  cervical  orifice,  and  held 
by  aids  in  a  suitable  position  above  the  superior  strait ;  the  foetus  of 
the  woman  was  then  placed  in  the  soft  and  dilated  uterine  orifice  in 
the  right  occipito-posterior  position.  Several  pupil-midwives,  pushing 
the  fretus  from  above,  readily  caused  it  to  enter  the  cavity  of  tiie  pelvis ; 
much  greater  effort  was  needed  to  make  the  head  travel  over  the  peri- 
na?um  and  clear  the  vulva ;  but  it  was  not  without  astonishment  that 
we  saw,  in  three  successive  attempts,  that  when  the  head  had  traversed 
the  external  genital  organs,  the  occiput  had  turned  to  the  right  ante- 
rior position,  while  the  face  had  turned  to  the  left  and  to  tne  rear  ;  in 
a  word,  rotation  had  taken  place  as  in  natural  labor.  We  repeated  the 
experiment  a  fourth  time,  but  as  the  head  cleared  the  vulva  the  occi- 
put remained  posterior.  Then  we  took  a  dead-born  foetus  of  the  pre- 
vious night,  but  of  much  larger  size  than  the  preceding  ;  we  placed  it 
in  the  same  conditions  as  the  first,  and  twice  in  succession  witnessed 
the  head  clear  the  vulva  after  having  executed  the  movement  of  rota- 
tion. Upon  the  third  and  following  essays,  delivery  was  accomplished 
without  the  occurrence  of  rotation  ;  thus  the  movement  only  ceased 
after  the  perina?um  and  vulva  had  lost  the  resistance  which  had  made 
it  necessary,  or,  at  least,  had  been  the  provoking  cause  of  its  accom- 
plishment." f 

This  interesting  experiment  shows  that  it  is  unnecessary  to  assume 
a  rotation  force  in  the  uterus  itself.  A  certain  amount  of  light  is 
thrown  upon  the  action  of  the  perineal  floor  by  the  clinical  fact  tbat  it 
is  always  the  most  dependent  portion  of  the  presenting  part  which  ro- 
tates to  the  front.  A  moment's  reflection  will  show  that  rotation, 
therefore,  takes  place  in  such  a  direction  that  the  sloping  surface  of 
the  child's  head  is  brought  into  correspondence  with  the  downward 
slope  of  the  perinseum.     Thus  it  sometimes  happens,  in  occipito-pos- 

*  Martel,  De  raccommodation  en  obstetrique,  vide  introduction, 
f  Ibid.,  quotation,  p.  93. 


176 


LABOR. 


terior  positions,  that  moderate  extension  occurs,  so  that  the  large  fon- 
tanelle  is  felt  below  the  plane  of  the  small  one.  In  this  case,  the  head 
rests  with  its  entire  length  upon  the  perineal  floor  ;  its  movements 
are  of  necessity  restrained  within  narrow  limits;  and,  if  extension 
persists,  the  pressure  of  the  opposing  ischio-pubic  ramus  directs  the 
forehead  under  the  arch  of  the  pubes.  When,  however,  the  head  is 
well  flexed  it  no  longer  corresponds  to  the  perineal  plane.  The  oc- 
ciput then  glides  downward,  and  is 
projected  forward  by  the  elastic  pelvic 
floor  until  the  anterior  parietal  boss  is 
forced  between  the  ischio-pubic  rami. 
As  the  occipital  end  of  the  flexed 
head  descends  downward  and  forward 
toward  the  pubic  arch,  the  frontal  ex- 
tremity encounters  the  resistance  of 
the  pelvic  wall  near  the  ileo-pectineal 
eminence.  If  the  pressure  upon  the 
head  were  in  all  parts  equal,  no  further 
progress  would  now  be  possible.  But 
it  is  not  equal.  The  backward  press- 
ure applied  to  the  frontal  portion  of 
the  head  is  exerted  upon  the  long  end 
of  a  lever,  and  works,  therefore,  at  a 
greater  mechanical  advantage  than 
that  directed  against  the  occiput.* 
At  the  same  time,  if  the  anterior  wall 
be  divided  by  a  line  drawn  on  a  level 
with  the  lower  margin  of  the  sym- 
physis, we  find  that  in  the  superior 
division  the  general  pelvic  pressure  di- 
minishes from  before  backward,  while 
below  the  line  indicated,  owing  to 
the  open  space  afforded  by  the  pubic 
arch  in  front,  pressure  diminishes  from  behind  forward.  Now,  in 
accordance  with  the  mechanical  principle  that  when  a  body  is  sub- 
jected to  varying  pressures  the  movement  will  take  place  in  the  direc- 
tion of  the  least  pressure,f  we  find  that  the  frontal  portion,  which  lies 
above  the  sub-pubic  plane,  turns  backward,  while  the  occiput,  which 
lies  below,  turns  under  the  arch  of  the  pubis. 

It  must  not  be  supposed,  in  imagining  the  results  of  rotation,  that 
the  movement  continues  until  exact  coincidence  of  the  sagittal  suture 
and  the  conjugate  is  reached.     Leishman  endeavored  to  measure  the 

*  Tarnier  et  Chantreuil,  Traite  de  I'art  des  accouchements,  p.  644. 
t  Stephenson,  On  the  Mechanism  of  Labor,  Obstet.  Jour,  of  Gr.  Brit,  and  Ire., 
October,  1878,  p.  405. 


Fig.  101— O,  B,  short  end  of  the  head 
lever ;  B,  F,  long  end  of  head  lever. 
(Tarnier  et  Chantreuil.) 


MECHANISM   OF   LABOR. 


irr 


divergence  between  the  two  after  the  head  had  escaped  from  under  the 
pelvic  arch,  by  stretching  a  cord  over  the  surface  of  the  head  from  the 
lower  border  of  the  symphysis  to  the  coccyx.  He  found  that  in  left 
occipital  positions  the  cord  crossed  the  lambdoidal  suture  about  an  inch 
to  the  right  of  the  small  fontanelle,  and  thence  extended  forward  to 
the  middle  of  the  opposite  orbit,  intersecting  the  median  line  at  or 
near  the  anterior  fontanelle.* 

In  emerging  from  the  pelvis,  the  two  tubera  parietalia  do  not  pass 
out  at  the  same  time.  In  place  of  this,  the  head  rolls  upon  its  side,  so 
that  in  left  occipital  positions  the  presentation  is  formed  by  the  upper 
and  posterior  part  of  the  right  parietal  bone,  and  in  right  occipital  posi- 
tions by  the  corresponding  territory  upon  the  left  parietal  bone. 

Extension. — As  the  head  clears  the  inferior  strait  it  distends  the 
perina3um,  and  converts  it  into  a  groove,  which  directs  the  occiput 
toward  the  vaginal  orifice.  With  the  descent  of  the  head  the  peri- 
ngeum  lengthens ;  between  the  pains  the  perina?um  retracts,  and  the 
head  recedes.  A  gradual  softening  results  from  the  continuance  of 
this  play,  and,  with  diminished  resistance  from  the  perinaeum,  the  oc- 
ciput descends  along  the  anterior  pelvic  wall,  the  trunk  enters  the 
cavity,  and  the  neck  finds  support  against  the  os  pubis.  Flexion  con- 
tinues until  the  occiput  engages  between  the  pubic  rami.  When  the 
resistance  of  the  anterior  bony  wall  is  no  longer  encountered,  the  sur- 
face of  the  child's  head  glides  forward  upon  the  perinaeum,  as  upon  an 
inclined  plane,  and  describes  a  circle  beneath  the  pelvic  arch,  of  which 
the  sub-occipito-bregmatic  diameter  forms  the  radius. 

The  extension  of  the  head,  which  is  an  essential  feature  of  the  fore- 
going movement,  is  the  resultant  of  two  forces,  derived,  first,  from  the 
uterus,  second,  from  the  pelvic  floor. 

The  uterine  action  is  transmitted  in  the  axis  of  the  superior  strait. 
With  the  occiput  fixed  beneath  the  pubic  arch  and  the  neck  resting 
against  the  inner  surface  of  the  pubes,  the  propulsive  force  is  exjjeuded 
upon  the  frontal  extremity  of  the  head,  and  this  causes  the  separation 
of  the  chin  from  the  thorax.  So  soon  as  the  forehead  passes  the  apex 
of  the  sacrum,  the  recoil  of  the  coccyx  and  the  elastic  perinaeum  drives 
the  fronto-occipital  diameter  forward  to  the  vulva,  which  now  looks  in 
a  nearly  vertical  direction.  When  the  bi-parietal  diameter  has  once 
passed  the  vaginal  orifice,  the  perinaeum  rapidly  retracts,  and,  as  it 
glides  over  the  face,  the  occiput  is  thrown  sharply  and  rapidly  upward 
against  the  pubes. 

External  Rotation.— After  the  birth  of  the  head,  the  face,  no  longer 
supported  by  the  perinaeum,  sinks  toward  the  anal  region.  At  the 
same  time,  or  w^ith  the  recurrence  of  a  pain,  the  head  makes  a  quartor- 

*  Leishman,  The  Mechanism  of  Parturition,  p.  84.     It  will  be  readily  under- 
stood, that  in  right  occipital  positions  the  cord  should  pass  from  the  left  of  the 
small  fontanelle  forward  to  the  right  orbit. 
12 


1  -c  LABOR. 

rotation,  the  occiput  turning  toward  the  thigh  corresponding  to  the 
side  to  which  it  was  originally  directed  (right  occipital  position,  right 
thif^h ;  left  occipital  position,  left  thigh),  and  the  face  to  the  internal 
surface  of  the  opposite  thigh.  This  movement  is  partly  a  restitution 
of  the  head  to  its  normal  direction,  and  partly  is  due  to  a  corresponding 
rotation  of  the  shoulders  in  the  pelvic  cavity.  To  understand  the 
mechanism  of  external  rotation  it  must  be  borne  in  mind  that,  in  the 
movement  of  rotation,  performed  by  the  head  in  its  transit  through  the 
pelvic  canal,  the  trunk  participates  to  a  diminished  extent  only.  Thus, 
Schatz  *  found,  in  the  frozen  section  made  by  Braune  through  the  ca- 
daver of  a  woman  who  died  in  the  second  stage  of  labor,  where  the  head 
had  originally  occupied  the  right  occipito-posterior  position,  that  the 
deviation  between  the  pelvic  extremity  and  the  head  was  measured  by 
an  angle  of  thirty  degrees,  and  between  the  head  and  trunk,  on  a  line 
with  the  shoulders,  by  an  angle  of  thirteen  degrees.  After  the  release 
of  the  head  from  the  vulva  the  torsion  ceases,  and  the  fetal  parts  re- 
sume their  natural  relations  to  one  another.  The  head,  therefore,  turns 
slightly  to  the  side,  as  it  accommodates  itself  to  the  direction  of  the 
shoulders.  This  first  movement  is  termed  "  restitution,"  and  is  much 
less  marked  in  occipito-anterior  than  in  occipito-posterior  positions.  The 
shoulders  assume  an  obhque  position,  until,  encountering  the  sloping 
pelvic  planes,  the  anterior  shoulder  rotates  forward,  and  the  bis-acromial 
diameter  approximates  to  the  antero-jiosterior  diameter  of  the  outlet. 
The  internal  rotation  of  the  shoulders  usually  takes  place  suddenly,  and 
is  accompanied  by  the  corresponding  movement  of  the  child's  head. 

Excessive  rotation  is  sometimes  observed.  Thus,  the  shoulders,  in 
place  of  turning  to  the  antero-postorior  diameter,  may  continue  in 
movement  until  they  occupy  the  oblique  diameter  of  the  opposing 
side,  the  posterior  shoulder  coming  to  the  front.  This  necessarily 
causes  faulty  external  rotation  of  the  head.  It  occurs  most  frequently 
in  occipito-posterior  positions,  f 

Expulsion  of  the  Trunk. — After  rotation,  the  anterior  shoulder 
passes  under  the  arch  of  the  pubes ;  the  trunk,  as  it  is  driven  down 
from  above,  becomes  bent  laterally,  and  the  posterior  shoulder  glides 
forward  upon  the  perineum  to  the  commissure  of  the  vulva;  both 
shoulders  then  make  the  exit  from  the  vaginal  canal  simultaneously. 
In  the  delivery  of  the  shoulders  the  bis-acromial  diameter  is  usually 
somewhat  oblique.  The  expulsion  of  the  trunk,  owing  to  the  previous 
dilatation  of  the  passage,  follows  with  rapidity ;  the  body  executes  a 
spiral  movement  until  the  hips  engage  at  the  outlet;  during  the 
birth  of  the  pelvis,  however,  the  bis-iliac  diameter  rotates  so  as  to 
approximate  to  the  line  extending  from  the  coccyx  to  the  pubes. 

*  Schatz,  Arch.  f.  Gynaek.,  Bd.  vi,  p.  413. 

t  DoHRN,  Ueber  die  Ursachen  fehlerhaftes  Drehung  der  Schultern,  etc.,  Arch.  f. 
Gynaek.,  Bd.  iv,  p.  363. 


MECHANISM   OF   LABOR. 


n9 


Abnormal  Mechanism  of  Labor.    (Vertex  Presentation.) 

In  the  proper  performance  of  the  various  mechanical  acts  of  labor, 
it  is  necessary  that  the  diameters  of  the  fetal  head  approximate  to 
those  of  the  canal  through  which  it  has  to  pass.  A  very  large  pelvis, 
or  a  very  small  head,  may  become  disturbing  factors  by  leading  to 
imperfect  flexion  and  rotation.  In  either  case,  with  a  lax  perinfpum 
and  gaping  vulva,  the  head  may  be  born  in  any  of  the  diameters  of  the 
pelvis.  Head-births  in  either  an  oblique  or  transverse  diameter  are, 
however,  extremely  rare.  They  are  attended  with  unusual  difficultv,  as 
the  occiput  has  to  traverse  a  longer  course  than  when  directed  forward 
under  the  pubic  arch. 

The  most  important  of  the  irregular  forms  results  from  the  rota- 
tion of  the  occiput,  in  occipito-posterior  positions,  backward  into  the 
hollow  of  the  sacrum.*  The  chief  condition  of  its  production  is  a 
partial  extension  of  the  head,  the  forehead  then  turning  anteriorly,  in 
accordance  with  the  law  that  the  most  dependent  portion  of  the  pre- 
senting part  is  moved  to  the  front. 


Fig.  102.— Illustrating  the  mechanism  of  labor  in  occipito-posterior  positions. 
(After  Schultze.l 

The  Mechanism  of  Occipito-posterior  Positions.— When  the  occiput 
turns  backward,  it  rests  upon  the  anterior  surface  of  the  sacrum  and 

*  Playfair  states  that  Dr.  Uvedale  West  found  the  frequency  of  this  back- 
ward rotation  was  four  times  to  the  hundred  in  occipito-posterior  positions. 
American  edition,  p.  265. 


180 


LABOR. 


upon  the  2)erina&um  ;  the  forehead  and  the  anterior  fontanelle  distend 
the  vulva.  If  the  rotation  is  incomplete,  the  anterior  parietal,  or  adja- 
cent frontal  bones,  are  seen  at  the  rima  pudendi ;  and,  as  the  frontal 
portion  is  born,  the  occiput  sweeps  forward  to  the  perineal  commissure. 
After  the  occiput  makes  its  exit,  the  neck  rests  upon  the  perineum, 
while  the  head  swings  backward,  describing  a  circle,  of  which  the  sub- 
occipito-bregmatic  diameter  forms  the  radius. 

Delivery  in  these  cases  is  apt  to  be  tedious,  and  often  demands  the 
aid  of  forceps. 

Configuration  of  the  Head  in  Vertex  Presentations. 

During  labor  the  various  head  diameters  of  the  foetus  undergo  ex- 
tensive modification  as  they  are  subjected  to  the  resistance  of  the  par- 
turient canal.  Of  these,  the  most  important  is  the  diminution  of  the 
sub-occipito-bregmatic,  the  occipito-frontal,  and  the  bi-temporal  diam- 
eters, with  compensatory  elongation  taking  place  in  a  line  running 
from  the  chin  to  a  point  in  the  sagittal  suture  situated  between  the 
apex  of  the  occipital  bone  and  the  large  fontanelle  (maximum  diame- 
ter of  Budin).  The  plastic  changes  mentioned  are  rendered  possible 
by  the  presence  of  the  fontanelles,  the  width  of  the  sutures,  the  plia- 


FiG.  103.— Outlines  showing  difference  between  head  of  child  at  birth  (1)  and  four  days  subse- 
quent to  delivery  (2).    (Budin.) 

bility  of  the  sagittal  borders  of  the  parietal  bones,  the  depressibility  of 
the  OS  frontis,  and  the  joint-like  movement  between  the  squamous  and 
basilar  positions  of  the  occipital  bone.  As  a  consequence  of  these  ana- 
tomical dispositions,  pressure  from  above  inclines  the  frontal  bones 
backward,  while  the  resistance  encountered  below  shoves  the  occipital 
bone  in  a  forward  direction.     These  movements  are  rendered  possible 


MECHANISM   OF    LABOR. 


ISl 


by  the  depression  of  both  frontal  and  occipital  bones  beneath  the 
adjacent  borders  of  the  parietal  bones;  at  the  same  time,  the  dragging 
thus  exerted  upon  the  latter,  front  and  rear,  increases  the  curve  of  the 
cranial  vault  along  the  line  of  the  sagittal  suture.  The  sharpness  of 
the  bend  at  the  summit  of  the  curve  is  more  or  less  pronounced,  ac- 
cording to  the  rigidity  of  the  channel  through  which  the  head  passes. 
In  cases  of  bii'th  with  the  occiput  to  the  rear,  the  head  is  often  drawn 
out  to  a  great  length,  the  occiput  forming  an  almost  vertical  line  with 
the  neck  and  shoulders,  while  in  front  the  forehead  and  parietal  bones 
slope  upward  to  the  vertex  in  nearly  the  same  plane. 

The  contour  of  the  head  is  still  further  modified  by  the  formation 
of  the  caput  succedaneura,  or  scalp-tumor,  a  swelling  developing  upon 
the  portion  of  the  presenting  part,  which  is 
subjected  to  diminished  pressure  from  the 
obstetric  canal,  and  which  in  consequence  be- 
comes the  seat  of  venous  hyperasmia,  oedema, 
and  extravasation.  The  formation  of  the 
tumor  is  usually  preceded  by  wrinkling  of 
the  scalp,  indicative  of  the  stronger  compres- 
sion above.  It  may  be  produced  within  the 
cervical  canal,  but  is  then  usually  of  insig- 
nificant size  and  of  small  practical  impor- 
tance. Indeed,  it  may  even  form  previous  to 
rupture  of  the  membranes  in  cases  where  the 
separation  of  the  bag  of  waters  from  the  con- 
tents of  the  uterine  cavity  is  complete,  and 
where,  we  have  seen,  the  water-pressure  below 
the  line  of  cervical  contact  with  the  head 
is  less  than  the  intra-uterine  pressure  above. 
Usually,  however,  it  is  developed  after  the  head  reaches  the  pelvic 
floor,  at  the  outlet  of  the  vagina,  the  situation  upon  the  scalp  often 
enabling  one  subsequent  to  delivery  to  diagnose  the  position  the  head 
had  occupied  within  the  pelvic  canal.* 

A  voluminous  scalp-tumor  is,  as  a  rule,  the  result  of  compression 
from  the  bony  canal,  and  forms,  therefore,  in  normal  pelves,  below 
the  narrowing  of  the  inferior  strait.  In  generally  contracted  pelves, 
however,  where  the  resistance  of  the  bony  canal  is  encountered  at  the 

*  The  tumor  forms,  in  left  occipito-anterior  positions,  upon  the  superior  posterior 
angle  of  the  right  parietal  bone,  encroaching  somewhat  upon  the  small  fonlanelle 
and  the  occiput;  in  right  occipito-anterior  positions,  upon  the  corresponding 
point  on  the  left  side  of  the  cranium.  In  occipito-posterior  deliveries  the  tumor 
develops  upon  the  anterior  superior  angle  of  the  parietal  bone  turned  to  the 
pubic -arch,  and  encroaching  upon  the  large  fontanelle.  and  even  upon  the  frontal 
suture.  If  the  head-rotation  is  complete,  and  the  head  is  detained  for  a  long 
period  at  the  vulva,  the  tumor  may  occupy  the  median  line,  and  thus  obscure  the 
diagnosis. 


Showing  shape  of 
head  in  occipito-posterior 
deliveries.  (Tarnier  et  Chan- 
treiiil. ) 


182 


LABOR. 


brim,  the  formation  of  an  enormous  scalp-tumor  may  precede  the  en- 
trance of  the  head  into  the  pelvis. 

According  to  Dessaut,*  the  scalp-tumor  is  usually  of  larger  size 
when  situated  upon  the  anterior  surface  of  the  head,  partly  because  of 
the  greater  laxity  of  the  tissues,  and  partly  because  of  the  longer  dura- 
tion of  labor  when  the  forehead  is  directed  to  the  front.  Its  length 
may  vary  from  a  half -inch  to  two  inches  or  more.  In  extreme  cases, 
where  the  labor  has  been  prolonged,  there  is  sometimes  found,  asso- 
ciated with  the  scalp-tumor,  a  separation  of  both  the  periosteum  and 
the  dura  mater  from  the  underlying  segment  of  the  cranium. 

Diagnosis. — The  diagnosis  of  cranial  presentations  by  external  pal- 
pation is  usually  not  difficult.     The  head  is  recognized  by  its  hardness, 


Method  of  j)erforniinK  external  palpation.    (Pinai  d.) 


its  rounded  form,  its  separation  from  the  trunk  by  the  neck,  and  the 
ease  with  which  ballottement  is  produced.  Sometimes,  by  pressure 
upon  the  cranial  bones,  a  peculiar  parchment-like  crackle  is  elicited, 
which  is  perceptible  even  through  the  abdominal  parietes.f  The 
breech,  on  the  contrary,  is  of  uneven  shape,  of  smaller  size,  and  of 

*  Tarnier  et  Chantreuil,  p.  686. 

t  Fasbender.  Monatsschr.  f.  Geburtsk.,  Bd.  xxxiii,  p.  435.  Dr.  P.  P.  Muiide 
has  recently  furnished  an  excellent  resume  of  the  subject  of  diagnosis  by  external 
examination  in  an  essay  termed  Obstetric  Palpation. 


MECHAXISM   OF   LABOR.  -^^^ 

softer  consistence.  The  feet  are  found  in  close  jjroximity.  Ballottemeut 
is  obscure  on  account  of  the  broad  connection  between  the  breech  and 
the  trunk.  Under  favorable  conditions  the  back  presents  upon  one  side 
of  the  uterus  a  broad,  palpable  surface  without  distinctive  bony  projec- 
tions. The  outline  of  the  dorsal  surface  may  be  rendered  more  distinct 
by  downward  pressure  exerted  over  the  fundus  upon  the  breech  of  the 
child.  The  position  of  the  child  is  determined — 1.  By  the  fetal  heart, 
which,  except  in  face-presentations,  is  heard  most  distinctly  over  the 
dorsal  surface  ;  2.  By  the  direction  of  the  feet,  which  are  situated  upon 
the  abdominal  side  of  t'.ie  child. 

Upon  examination  made  per  vagiuam  the  head  is  felt  as  a  hard, 
round,  smooth  body,  characterized  by  the  sutures  and  fontanelles,  and 
sufficiently  large  to  till  the  space  of  the  pelvis.  Before  the  rupture  of 
the  membranes,  investigations  should  be  conducted  in  the  intervals  be- 
tween the  pains,  i.  e.,  vv^hile  the  membranes  are  lax  and  depressible.  If 
the  head  is  high,  and  retreats  before  the  examining  finger,  it  should  be 
steadied  by  counter-pressure  applied  to  the  fundus  uteri  through  the 
abdominal  walls. 

The  sutures  and  fontanelles  are  best  made  out  after  rupture  of  the 
membranes.  In  passing  the  extremity  of  the  index-finger  backward 
over  the  cranium  toward  the  sacrum,  the  sagittal  suture  is  usually  en- 
countered. At  the  extremities  of  the  sagittal  suture  the  two  fonta- 
nelles are  perceived,  distinguishable  from  one  another  by  the  differences 
in  size  and  shape.  In  exceptional  cases  the  extreme  compression  of 
the  bones  of  the  skull  may  render  the  large  fontanelle  scarcely  recog- 
nizable ;  in  others,  again,  the  presence  of  membranous  spaces  in  the 
line  of  the  sagittal  suture,  fissures  at  the  apex  of  the  occipital  bone,  or 
the  existence  of  ossa  triquetra  near  the  site  of  the  small  fontanelle,  may 
cause  perplexity,  and  lead  to  errors  in  the  diagnosis  of  head  positions. 
It  is  therefore  well  to  bear  in  mind,  as  special  marks  of  distinction, 
that  the  small  fontanelle  furnishes  the  meeting-point  of  three  sutures, 
while  four  sutures  meet  at  the  large  fontanelle. 

The  sagittal  suture  pursues  a  straight  course,  forming  a  right  angle 
with  the  coronal  and  an  obtuse  angle  with  the  lambda  suture.  An- 
teriorly it  is  continuous  with  the  frontal  suture;  posteriorly  it  ends 
abruptly  at  the  occipital  bone.  The  lambda  suture,  which  is  the  only 
one  liable  to  be  mistaken  for  the  preceding,  is  distinguished  by  its 
curvilinear  direction,  by  the  greater  thickness  of  the  parietal  borders, 
and  by  the  depression  of  the  occipital  beneath  the  parietal  bones. 

When  the  sutures  are  masked  by  the  presence  of  a  large  scalp- 
tumor,  it  is  still  possible  in  most  cases  to  diagnose  the  position  by 
pushing  the  finger  up  behind  the  symphysis  pubis  and  feeling  for 
the  ear. 


jg^  LABOR. 

CHAPTER  X. 

MECHANISM   OF  LABOR.— (Continued.) 

Pace  presentations. — Frequency. — Causes. — Mechanism. — Descent  and  extension. — 
Rotation. — Flexion. — External  Rotation. — Abnormal  mechanism. — Configura- 
tion of  head.  — Diagnosis. — Prognosis. — Treatment. — Brow  presentations. — 
Breech  presentations. — Causes. — Diagnosis. — Mechanism, — Irregular  mechan- 
ism,— Configuration. — Prognosis. — Treatment, 

Face  Presejsttatioxs, 

Ix  facial  presentations,  in  place  of  the  normal  attitude  of  the  foetus, 
the  chin  is  extended,  the  occiput  is  reflected  against  the  neck,  and  the 
face  with  the  frontal  portion  of  the  skull  occupies  the  entrance  to  the 
pelvis.  It  is  not  a  very  common  anomaly,  having  occurred,  according 
to  Pinard,  320  times  in  81,711  confinements  at  the  Maternitc  in  Paris, 
or,  in  round  numbers,  once  in  250  cases.* 

Causes. — The  causes  of  face  presentations  are  imperfectly  known. 
Clinical  observation  has,  however,  succeeded  in  connecting  the  exten- 
sion of  the  head  in  the  pelvic  canal  with  a  variety  of  predisposing  con- 
ditions. To  Ahlfeld  \  we  are  indebted  for  a  collection  of  associated 
events  derived  from  a  careful  analysis  of  well-observed  cases.  From 
these,  the  following  are  selected  because  of  their  more  palpable  con- 
nection with  the  phenomenon  in  question  : 

Separation  of  the  chin  from  the  chest,  resultiiig  from  congenital  en- 
largement of  the  thyroid  gland ;  from  increased  size  of  the  chest  in- 
terfering with  flexion ;  from  stricture  of  the  cervix  about  the  neck  of 
the  child,  the  uterine  walls  adding  to  the  circumference  of  the  thorax ; 
from  the  mobility  of  the  foetus,  either  because  of  its  small  size  or  from 
excess  of  amniotic  fluid  ;  from  oblique  positions  of  the  child  and  of  the 
uterus,  especially  in  cases  of  rapid  escape  of  the  amniotic  fluid ;  and 
from  coiling  of  the  cord  around  tlie  head  of  the  foetus,  Ilecker  J  lays 
great  stress  upon  the  shape  of  the  child's  head,  and  has  endeavored 
to  establish  a  connection  between  face  presentations  and  unusual  length 
of  the  occiput.  To  be  sure,  after  birth  in  face  presentations  the  hind- 
head  is  often  found  to  nearly  equal  in  length  the  anterior  portion,  arid 
it  is  easy  to  see  that,  were  such  the  case  at  the  beginning  of  labor,  the 
question  of  extension  or  flexion  would  always  be  in  suspense ;  but,  in 
most  cases,  the  shape  is  the  effect  rather  than  the  cause  of  the  presen- 
tation. Still,  Hecker  and  others  have  reported  instances  where  the 
elongation,  instead  of  proving  temporary,  persisted  after  delivery,  and 
therefore,  it  was  fair  to  assume,  had  existed  as  a  pre-natal  condition. 

*  Charpentier,  Contributions  a  I'etude  des  presentations  de  la  face,  p.  15. 
t  Ahlfeld,  Die  Entstehung  der  Stirn-  und  Gesichtslagen. 
X  Hecker,  Ueber  die  Schadelform  bei  Gesichtslagen. 


MECHANISM   OP   LABOR. 


18^ 


The  resistance  encountered  by  the  occiput,  which  converts  partial 
into  complete  extension  of  the  head,  may  be  furnished  by  either  the 
uterine  or  the  pelvic  walls. 

Most  writers  ascribe  great  importance  to  oblique  positions  of  the 
foetus  and  of  the  uterus  in  the  etiology  of  face  presentations.  In  mul- 
tiparas, the  former  are  not  uncommon  during  pregnancy,  the  head 
then  resting  upon  an  iliac  fossa.  As  a  rule,  however,  the  first  pains 
straighten  the  foetus,  the  narrowing  of  the  uterus  in  its  transverse 
diameter  serving  to  press  the  breech  toward  the  fundus  and  the  head 
into  the  pelvis.  So  long  as  the  back  of  the  child  is  directed  downward, 
the  rectification  would  inevitably  be  followed  by  head-flexion.  When, 
however,  the  back  is  turned  toward  the  fundus,  and  the  change  to  the 
vertical  attitude  is  not  readily  effected,  the  pressure  of  the  adjacent 
uterine  wall  may,  during  contraction,  act  in  a  special  degree  upon  the 
occiput,  and  direct  it  backward  toward  the  neck,  while  the  forehead 
sinks  forward  into  the  brim  of  the  j^elvis.  This  movement  is  often 
temporary,  and  with  the  descent  of  the  child  the  resistance  encoun- 
tered by  the  forehead  may  exceed  that  met  with  from  the  occiput,  and 
thus  in  the  end  flexion  may  follow  in  the  ordinary  manner.  If,  how- 
ever, the  extension  continues,  a  point  is  finally  reached  at  which  the 
propelling  force  is  exerted  specially  in  the  direction  of  the  chin,  now 
converted  into  the  short  end  of  the  lever,  and  the  face  presentation 
becomes  complete.  In  the  same  way,  extension  may  be  produced  when 
the  occiput  is  arrested  at  the  linea  iunominata,  an  accident  most  likely 
to  occur  in  transverse  narrowing  of  the  pelvis,  and,  again,  in  flattened 
pelves  when  the  bi-parietal  diameter  is  arrested  by  the  contracted  con- 
jugate. The  mechanism  of  head- flexion  may  likewise  be  interfered 
with  by  a  prolapsed  extremity  encroaching  upon  the  pelvic  space. 

In  lateral  obliquity  of  the  uterus,  the  curvature  of  the  uterine  canal 
favors  the  production  of  face  presentations  when  the  back  of  the  child 
conforms  to  the  convexity  of  the  lower  surface,  as  the  propelling  force, 
which  is  transmitted  in  the  axis  of  the  uterus,  then  passes  along  the 
anterior  aspect  of  the  foetus,  and  increases  the  tendency  of  the  fore- 
head to  descend. 

While  in  vertex  presentations  the  left  dorsal  positions  are  nearly 
three  times  as  frequent  as  the  right,  in  face  presentations  the  differ- 
ence is  very  small.*     Both  Duncan  f  and  Schroeder  J  ascribe  this  rela- 

*  Statistics  are  as  yet  not  sufficiently  numerous  to  determine  the  question  as  to 
which  position  actually  occurs  most  frequently.  Dubois  and  Desormeaux  (Diction- 
naire,  in  thirty  volumes,  p.  364)  reported  eighty-five  cases.  Of  these,  in  forty-five 
the  chin  was  turned  to  the  right,  while  in  thirty-eight  it  was  directed  to  the  left. 
Dr.  A.  Walther  (Winckel's  Berichte,  Bd.  iii.  p.  212)  reported  from  the  Dresden 
Lying-in  Institute  thirty-one  cases.  Of  these,  the  chin  was  turned  to  the  left 
twenty-one  times,  to  the  right  ten  times. 

t  Duncan,  Edinburgh  Obstet.  Trans.,  vol.  ii,  p.  108. 

X  Schroeder,  Lehrbuch  der  Geburtshiilfe.  p.  182. 


186 


LABOR. 


tive  preponderance  of  face  presentations  with  the  chin  directed  to  the 
left  to  the  constancy  of  right  lateral  obliquity  of  the  uterus. 

Alilfeld  *  mentions  further  that  it  is  not  infrequent  for  extension 
to  take  place  within  the  pelvic  cavity,  the  arrest  of  the  occiput  result- 
ing from  an  unusual  projection  of  the  spines  of  the  ischia. 

The  Mechanism  of  Face  Presentations. 

As  in  vertex  presentations,  the  dorsum  of  the  child  may  be  turned 
to  the  right  or  to  the  left  side.     The  position  of  the  face  is  usually 
designated  by  the  direction  of  the  chin.     We  distinguish,  therefore : 
0'.  <i  {-^t  Right  mento-iliac  positions  (chin  to  right  ilium) ; 

^     ^    Left  mento-iliac  positions  (chin  to  left  ilium). 
'■ '  ■  Most  frequently  the  face  occupies  the  right  oblique  diameter  of  the 

pelvis.     The  common  positions   are,  therefore,  the   right  mento^jliac 

posterior  and  the  left  mentojriliac 
anterior ;  still,  it  is  by  no  means 
rare  for  the  face  to  enter  the 
pelvis  transversely,  probably  be- 
cause of  the  frequent  association 
of  face  presentations  with  a  nar- 
rowing of  the  conjugate. 

Descent  and  Extension.  — 
These  two  movements,  like  de- 
scent and  flexion  in  vertex  pre- 
sentations, are  conjoined  —  not 
distinct  from  one  another.  At 
the  brim,  the  large  fontanelle  is 
easily  reached,  while  the  chin  is 
inaccessible.  As  the  vertebral 
column  is  situated,  in  face  pres- 
entations, nearer  to  the  chin  than 
the  occiput,  extension  is  accom- 
plished in  obedience  to  the  same 
rules  which  produce  flexion  in 
vertex  cases.  With  the  descent 
of  the  head  through  the  pelvic 
channel,  the  chin  sinks  deeper 
and  deeper,  while  the  occiput  is 
pushed  backward  and  pressed 
firmly  against  the  dorsal  surface 
of  the  child.  The  degree  of  extension  at  the  different  stages  of  the 
descent  is  measured  by  the  relative  positions  of  the  chin  and  the  large 
fontanelle. 

The  engagement  of  the  head  is  usually  slow  and  accomplished  with 
*  Ahlfeld,  Ioc.  cif.,  p.  62. 


-Attitude  of  the  head  in  face  presenta- 
tions.   (Rib^mont.) 


MECHANISM    OF   LABOR. 


187 


difficulty,  owing  to  the  fact  that  the  neck  and  posterior  portion  of  the 
head  enter  the  excavation  at  the  same  time.  The  descent  of  the  head 
is  normally  limited  by  the  length  of  the  child's  neck,  as  it  is  only  in  the 
case  of  a  very  small  child,  or  exceptionally  roomy  pelvis,  that  the  head 
and  upjjer  portion  of  the  thorax  can  enter  the  pelvis  simultaneously. 

When  the  face  reaches  the  pelvic  floor,  a  slight  degree  of  lateral 
obliquity  is  produced,  the  cheek  directed  toward  the  pubes  advancing 
somewhat  more  rapidly  than  the  one  turned  to  the  sacrum. 

Rotation. — When  the  chin  has  descended  along  the  lateral  or  pos- 
terior wall  of  the  pelvis  until  the  thorax  reaches  the  linea  innominata, 
further  progress  is  only  rendered  possible  when  the  chin  rotates  forward 
and  engages  beneath  the  arch  of  the^pulSei]    TfirTrrenhanism  of  ^Hm^^^ 


Fig 


Engagement  of  the  head  in  face  presentations.    (Tarnier  et  Chantreuil.) 


rotation  is  the  same  portrayed  in  vertex  presentations.  When  extension 
is  complete,  the  chin,  as  the  most  dependent  portion,  glides  downward 
and  forward  upon  the  ]3eriaa^um,  and  the  malar  bone  is  pressed  between 
the  pubic  rami.  We  have  seen  already  that  the  pressure  above  the 
pubic  arch  diminishes  from  before  backward,  while  below  it  diminishes 
from  behind  forward.  In  accordance  with  the  mechanical  principle, 
that  a  body  subjected  to  varying  pressures  moves  in  the  direction  of 
least  pressure,  the  chin  or  deeper  portion  turns  to  the  front,  while  the 
cranial  vault  rotates  into  the  hollow  of  the  sacrum.  To  this  movement 
the  unequal  length  of  the  two  extremities  of  the  lever,  measuring  from 


188 


LABOR. 


the  malar  bone  to  the  top  of  the  forehead  on  the  one  side,  and  from  the 
malar  bone  to  the  chin  upon  the  other,  contributes  in  an  important 
degree.* 

Flexion. — After  rotation,  the  chin  emerges  beneath  the  pubic  arch, 
the  shoulders  press  upon  the  base  of  the  skull,  the  perinseum  becomes 
rounded  by  the  cranial  vault,  and,  finally,  as  the  head  performs  the 
movement  of  flexion  in  obedience  to  the  forward  impulse  imparted  by 
the  perinaBum,  the  chin  rounds  the  symphysis,  while  the  mouth,  the 
nose,  the  brow,  the  vertex,  and  the  occiput  appear  in  succession  at  the 
posterior  commissure  of  the  vulva. 

External  Rotation. — When  the  delivery  of  the  head  is  complete, 
the  shoulders  rotate  Tnto  the  antero-posterior  diameter  of  the  pelvis, 
the  chin  turning  in  correspondence,  in  right  mento-iliac  positions,  to 
the  right  thigh  ;  in  left  mento-iliac  positions,  to  the  left  thigh. 


Abnoemal  Mechanism. 

In  a  foetus  of  small  size,  the  face  may,  when  it  meets  with  slight 
resistance  from  the  perinaeum,  be  borne  in  any  of  the  pelvic  diameters. 
Instances  of  spontaneous  delivery  without  anterior  rotation  of  the  chin 


Fig.  108.— Mechanism  of  face  presentations.    (Scbultze.) 

are,  however,  extremely  rare.     The  egress  of  the  face  in  the  transverse 
diameter  is  possible  in  a  shallow,  rachitic  pelvis,  flattened  in  the  conju- 
gate at  the  brim,  and  wide  between  the  ischia  at  the  outlet.     The  head 
*  Tarnier  et  Chantreuil,  he.  cit.,  p.  658. 


MECHANISM   OF   LABOR. 


189 


emerges  with  the  chin  resting  upon  one  of  the  ischio-pubic  rami, 
around  which  the  rotation  of  the  mento-occipital  diameter  takes  place. 
As  the  movement  is  associated  with  excessive  stretching  of  the  neck  it 
is  evident  that  its  execution  is  favored  by  the  tensile  condition  of  the 
tissues  which  follows  death  of  the  foetus. 

At  full  terra,  the  face  presenting,  spontaneous^delivery  in  mento- 
posterior positions  is  notj)racticable.  ^TiTs  becomes  evident  when  we 
reflect  that,  owing  to  the  length  of  the  sacral  wall,  the  chin  can  not  de- 
scend to  the  fourchette  without  an  incredible  flattening  of  the  cranial 


Fig.  109.— Face  presentation,  chin  to  the  rear.    (Hodge.) 

vault  and  the  simultaneous  entrance  of  the  chest  into  the  pelvic  cavity. 
It  is  claimed,  however,  that  when  the  head  is  small  and  compressible  it 
may  stretch  either  the  sacro-sciatic  ligaments  when  oblique,  or  the 
perinaeum  after  passing  the  extremity  of  the  sacrum,  to  an  extent 
sufficient  to  permit  the  descent  of  the  occiput  beneath  the  pubic  arch, 
and  the  conversion  of  the  face  into  a  vertex-presentation. 


CONFIGUKATION    OF   THE    HeAD    IN   FaCE    PRESENTATIONS. 

In  face  presentations  the  vault  of  the  cranium  is  flattened,  so  that 
the  sagittal  suture  runs  from  fontanelle  to  fontanelle  in  nearly  a  hori- 
zontal line  ;  the  squamous  portion  of  the  occipital  bone  is  pushed  back- 
ward, while  in  both  the  occipital  and  frontal  bones  the  convexity  is  in- 
creased. As  a  result,  there  is  an  augmentation  of  the  transverse,  the 
occipito-frontal,  and  occipito-mental  diameters,  while  the  sub-occipito- 
bregmatic  is  diminished.     The  maximum  diameter  either  corresponds 


190 


LABOR. 


Fig.  110.— Outline  of  head  born  with  face  presenting. 


to  the  occipito-mental,  or  terminates  posteriorly  at  a  point  below  the 

apex  of  the  occiput.* 

The  sero-sanguineous  tumor,  which  forms  upon  the  presenting  part 

as  a  consequence  of  the  diminished  pressure,  occupies  the  lower  portion 

of  the  malar  region,  and 
the  corner  of  the  mouth 
(left  mento-iliac  position, 
left  cheek ;  right  mento- 
iliac  position,  right  cheek) 
in  mento-anterior  positions, 
and  the  upper  portion  of 
the  malar  region,  and  even 
the  eye,  in  mento-posterior 
positions.  The  integu- 
ments of  the  cheek  assume 
a  blackish-blue  color ;  the 
tumefaction  of  the  lids  is 
such  that  at  birth  the  eyes 
are  closed,  and  sanguineous 

effusions  are  found  upon  the  ocular  conjunctiva;  and  the  inoutii,  when 

involved,  becomes  swollen  and  distorted,  so  that  suction  is  sometimes 

interfered  with  for  several 

days  after  birth. 

Diagnosis. — At  a    time 

when  a  portion  of  the  head 

still  remains  above  the  level 

of    the    pelvic   brim,   it   is 

not  infrequently  possible  to 

form  a  diagnosis  from  ex- 
ternal manipulations  alone. 

Thus,     by     making     deep 

pressure   with   the    tips   of 

the  fingers  above  the  sym- 
physis  pubis,  the  cranium 

may,   under    favorable   cir- 
cumstances, be  recognized 

upon  one  side  of  the  pelvis, 

together    with     the     sharp 

angle  formed  at  the  neck 

between    the    occiput    and 

the  dorsum  of  the  foetus. 

tinctness  over  the   anterior 


Fig.  111.— Same  head  five  days  later.    (Budin.) 


As  the  heart  is  heard  with  greatest  dis- 
portion  of   the  chest  in   face  presenta- 
tions, confirmatory   evidence   of  the   latter  is  afforded   by  detecting 
the  presence  of  the  fetal  extremities,  and  the  heart-sounds  upon  the 
*  Budin,  loc.  ciL,  p.  77. 


MECHANISM  OF  LABOR.  J9JL 

same,  instead  of,  as  in  vertex  presentations,  upon  opposite  sides  of 
the  trunk. 

Upon  internal  examination,  the  distinct  peculiarities  are  a  high 
position  of  the  presenting  part,  a  flattening  of  the  vaginal  fornix,  and, 
through  the  intervening  tissues,  the  recognition  of  the  smooth  forehead, 
contrasting  with  the  uneven  surface  of  the  face.  Through  the  dilated 
cervix  the  finger  detects  the  forehead,  the  bridge  of  the  nose,  the 
nostrils,  the  orbits,  the  malar  bones,  the  alveolar  processes  of  the  jaw, 
the  mouth,  and,  when  extension  is  complete,  the  pointed  chin.  In- 
stances have,  indeed,  been  recorded  where,  in  advanced  labor,  the  dis- 
torted face  has  been  confounded  with  the  breech,  the  inexperienced 
observer  mistaking  the  swollen  cheeks  for  the  "nates,  the  malar  bones 
for  the  ischia,  the  nose  for  the  tip  of  the  coccyx,  the  oedematous  eyelids 
for  the  scrotum,  and  the  mouth  for  the  anus.  Such  an  error  is  best 
avoided  by  deliberation  in  exploring  the  presenting  part.  With  proper 
care  the  smooth  forehead,  the  bridge  of  the  nose,  the  hard  orbital 
borders,  the  chin,  and  especially  the  mouth,  through  which  the  jaws 
can  be  felt,  afford  sufficient  data  for  a  correct  diagnosis. 

Prognosis. — According  to  the  statistics  of  Winckel,*  the  mortality 
of  the  children  in  face  presentations  amounted  to  thirteen  per  cent, 
while  that  of  the  mothers  reached  as  high  as  six  per  cent.  Thus, 
though  spontaneous  delivery  is  the  rule  in  face  presentations,  the 
dangers  to  both  mother  and  child  are  considerably  greater  than  in 
vertex  presentations.  The  causes  of  the  less  favorable  prognosis  are 
to  be  looked  for  in  the  increased  peripheral  head  measurements,  which 
engage  successively  in  the  different  planes  of  the  obstetric  canal,  and 
consequently  from  the  increased  reciprocal  pressure  exerted  between 
the  head  and  the  soft  parts,  and  partly  from  the  compression  of  the 
veins  of  the  neck  by  the  anterior  wall  of  the  pelvis.  Though  the 
average  length  of  labor  does  not  much  exceed  that  of  normal  presen- 
tations,! the  duration  is  more  readily  affected  by  minor  disturbances, 
such  as  weak  pains,  moderately  contracted  pelves,  and  rigidity  of  the 
obstetric  canal.  At  the  same  time,  the  prolongation  of  labor  in  these 
cases  is  attended  by  more  disastrous  consequences,  and  calls  more 
frequently  for  the  resources  of  art  to  complete  the  delivery. 

Treatment— The  first  rule  in  the  treatment  of  face  presentations  is 
to  carefully  avoid  prematurely  rupturing  the  membranes.  The  face  is 
ill  adapted  to  serve  the  purpose  of  a  dilator  to  the  cervical  canal,  and 
early  rupture  is  apt  to  be  followed  by  complete  escape  of  the  amniotic 
fluid— an  accident  always  to  be  dreaded,  but  specially  serious  in  face- 
presentations,  where  the  umbilical  cord  is  exposed  to  pressure  between 
the  anterior  surface  of  the  child  and  the  uterine  wall.  Examinations 
made  with  a  view  to  diagnosis  should  therefore  be  conducted  Avith 

*  Winckel,  Pathologie  der  Geburtshiilfe,  p.  89. 
f  Walther,  Wingkel's  Berichte,  Bd.  iii.  p.  315. 


192 


LABOR. 


great  care,  during  an  interval  between  the  pains,  and  their  repetition 
should  be  avoided  when  the  requisite  information  has  once  been  ob- 
tained. During  the  progress  of  the  first  stage  of  labor,  it  is  recom- 
mended to  place  the  mother  upon  the  side  toward  which  the  chin  of 
the  child  is  turned,  with  a  view  of  favoring  extension  and  rotation. 

Because  of  the  uncertainties  of  the  prognosis  in  face  presentations, 
many  manoeuvres  have  been  proposed  for  the  conversion  of  the  latter 
into  normal  presentations.  The  manipulations  chiefly  recommended 
consist  of  either  pushing  up  the  face  or  drawing  down  the  occiput, 
with  the  fingers  passed  through  the  cervical  canal.  Though  occasion- 
ally successful,  they  have  been  discountenanced  at  least  in  mento-an- 
t'erior  positions  by  most  obstetric  writers,  because  experience  has  shown 
the  results  to  be  by  no  means  commensurate  with  the  dangers  incurred. 
Schatz  *  has,  however,  suggested  a  rational  plan  for  reducing  the  ex- 
tended head  by  external  manipulations  only,  which  avoids  the  objec- 
tions to  the  earlier  methods.  His  manoeuvre  consists  in  restoring  the 
normal  attitude  of  the  body  by  flexing  the  trunk,  and  leaving  the  head 
to  resume  spontaneously  its  proper  position  as  it  sinks  into  the  pelvis. 
It  is  performed  by  seizing  the  shoulder  and  breast  with  the  hand 
through  the  abdominal  walls ;  then  lifting  the  chest  upward  and  press- 
ing it  backward,  at  the  same  time  steadying  or  raising  the  breech  with 
the  other  hand  applied  near  the  fundus,  so  as  to  make  the  long  axis  of 


Figs.  112-114.— Diagram  showing  Schatz's  method  of  converting  face  presentations  into  vertex 

presentations. 

the  child  conform  to  that  of  the  uterus,  and,  finally,  pressing  the  breech 
directly  downward.  As  the  child  is  raised,  the  occiput  is  allowed  to 
descend,  and  then,  as  the  body  is  bent  forward,  head-flexion  is  pro- 
duced by  the  resistance  of  the  side  walls  of  the  pelvis.     Schatz  illus- 

*  Schatz,  Die  Umwandlung  von  Gesichtslage,  etc.,  Arch.  f.  Gynaek..  Bd.  v, 
p.  313. 


MECHANISM   OF   LABOR.  ^93 

trates  these  movements  by  the  accompanying  diagrams.  If,  owing  to 
its  elevation,  the  head  tends  to  move  to  one  side  when  backward  press- 
ure is  made  upon  the  chest,  the  place  of  the  pelvic  wall  may  be  sup- 
plied by  external  pressure  exerted  by  an  assistant.  The  time  for  at- 
tempting this*  manipulation  is  previous  to  the  rupture  of  the  mem- 
branes. The  requisites  for  success  are  experience  in  mapping  out  the 
fetal  outlines  by  external  palpation,  and  the  absence  of  abdominal  and 
uterine  irritability.  After  rupture  of  the  membranes,  great  care  must 
be  exercised  in  vaginal  explorations,  to  avoid  injuring  the  eves  or 
exciting  premature  respiratory  movements  by  allowing  air  to  enter  the 
mouth. 

If  the  chin  remains  persistently  directed  to  the  rear,  rotation  may 
sometimes  be  promoted  by  either  pressing  forward  with  two  fingers 
upon  the  lower  jaw,  or  by  pushing  the  forehead  backward  and  upward, 
to  produce  a  deep  descent  of  the  chin.  To  be  effective,  either  manipu- 
lation should  be  executed  during  a  pain.  Hodge  advocates  the  vectis, 
and  others  a  blade  of  the  forceps,  as  of  use  in  correcting  mento-poste- 
rior  positions.  As  a  rule,  however,  good  pains  and  complete  extension 
are  the  conditions  most  likely  to  effect  the  forward  movement  of  the 
chin.  It  is  practically  of  importance  to  bear  in  mind  that  tardy  rota- 
tion is  characteristic  of  face  presentations.  If,  however,  the  face  re- 
mains persistently  turned  to  the  rear,  before  resorting  to  craniotomy, 
an  attempt  to  produce  head  flexion  by  Baudelocque's  method  is  ad- 
missible. This  consists  in  making  upward  pressure  with  two  fingers 
— first  upon  the  chin,  and  then  in  succession  upon  the  fossae  canin^e 
and  upon  the  brow.  Ziegenspeck  *  has  recently  reported  a  case  where 
interference  was  dela3'ed  until  uterine  rupture  threatened,  in  Avhich 
he  succeeded  in  flexing  the  head  by  combining  the  method  of  Bau- 
delocque  with  that  of  Schatz.  By  the  latter,  an  assistant  succeeded 
in  raising  the  brow  to  the  level  of  the  pelvic  brim,  while  Ziegen- 
speck used  pressure  through  the  abdominal  walls  upon  the  occiput, 
and  with  the  internal  hand  upon  the  face,  until  a  vertex  presenta- 
tion was  effected.  The  child  was  born  living,  and  the  mother  made 
a  good  recovery.  The  treatment,  in  cases  where  all  measures  prove 
ineffective  to  secure  a  favorable  change  of  position,  and  dangers  ac- 
crue from  delay  to  either  mother  or  child,  belongs  to  the  domain  of 
operative  midwifery. 

During  head-expulsion  caution  must  be  used  in  supporting  the 
perineum,  in  order  not  to  injure  the  neck  by  too  strong  forward  press- 
ure against  the  anterior  wall  of  the  pelvis. 

It  is  safe  to  assure  the  bystanders  that  the  distortion  of  the  face  and 
the  extension  of  the  head  after  delivery  will  disappear  spontaneously  in 
the  course  of  from  twenty-four  to  forty-eight  hours. 

*  Ziegenspeck,  Beitrag  zur  Behandlung  der  Gesichtslagen  klinische  Vortrage. 

No.  284. 

13 


194 


LABOR. 


Brow  Presentations. 

In  brow  presentatious  the  head  occupies  a  position  intermediate 
between  flexion  and  extension.  Of  necessity  every  face  presentation 
has  become  such  after  first  passing  through  the  frontal  stage.  A  tem- 
porary dip  of  the  large  fontanelle  in  the  earlier  period  of  labor  is  by  no 
means  uncommon.  With  the  advance  of  the  head,  however,  the  resist- 
ance encountered  usually  causes  the  complete  descent  of  either  the  chin 
or  the  occiput.  The  causes  of  brow  presentations  are,  in  the  main,  the 
same  as  those  given  for  presentations  of  the  face,  viz.,  obliquity  of  the 
uterus  and  foetus,  enlargements  of  the  neck  and  thorax,  contracted 
pelvis,  excessive  mobility  of  the  foetus,  and  partial  cervical  stricture. 

The  diagnosis  is  made  by  recognizing  the  apex  of  the  forehead  in 
the  pelvic  canal,  with  the  orbits  and  the  root  of  the  nose  upon  one 
side,  and  the  large  fontanelle  and  parietal  bones  upon  the  other.     At 

the  brim  the  frontal  suture 
is    usually    transverse,    but 
becomes  oblique  in  its  prog- 
ress toward  the  pelvic  outlet. 
A  small  head  may  pass 
through  a  roomy  pelvis,  tlie 
l)row     ])resenting,    without 
injury  to  either  mother  or 
child.      In   the  mechanism 
of     delivery    the    forehead 
turns  to   the  front  and  ap- 
pears at  the  vulva,  the  upper 
maxilla  resting  against  the 
symphysis  and  the  cranium 
lying  in  the  hollow  of  the 
sacrum  and  upon  the  peri- 
nfeum.     The  exit  is  accomplished  by  the  cranial  vault  first  sweeping 
forward  over  the  perinaeum ;  the  upper  Jaw,  the  mouth,  and  the  chin 
afterward  making  their  appearance  beneath  the  symphysis  pubis. 

Sometimes,  though  usually  only  when  the  forceps  is  used,  the 
head  may  be  delivered  in  the  transverse  diameter.  In  spontaneous 
cases  the  superior  maxilla  finds  a  point  of  support  against  one  ischio- 
pubic  ramus,  while  the  cranium  rotates  transversely  through  the  vulva. 
When  the  face  turns  posteriorly,  delivery  of  a  living  child  is  scarcely 
possible. 

The  configuration  of  the  head  is  very  striking.  The  swelling  of 
the  integuments  extends  from  the  root  of  the  nose  to  the  upper  angle 
of  the  large  fontanelle.  The  forehead  is  nearly  perpendicular,  while 
the  parietal  and  occipital  bones  form  a  slope  which  inclines  downward 
and  backward.     The  mento-frontal  and  sub-occipito-frontal  diameters 


Fig.  115.— Outline  of  head  after  delivery,  the  brow 
presenting.    (Budin.) 


MKCriANlSM   OF   LABOR. 


195 


are  increased,  while  the  distance  between  the  chin  and  a  point  in  the 
sagittal  snture  anterior  to  the  occiput  is  diminished.  These  changes 
impart  to  the  head  a  triangular  'shape.  The  peculiar  formation  is  ex- 
plained by  the  compression  of  the  occiput  between  the  pelvis  and  the 
dorsal  surface  of  the  child,  and  the  compensatory  elongation  which 
takes  place  in  the  direction  of  the  forehead. 

The  prognosis  isjess  favorable  than  in  vertex  presentations,  but  is 
by  no  means  so  sinister  as  is  popularly  supposed.    Many  cases  of  origi- 


PiG.  116.— Brow  presentation,  subsequently  converted  into  that  of  the  face.*    (Maternity 

Hospital.) 

nal  brow  presentations  become  converted  into  face  or  vertex  presenta- 
tions during  the  progress  of  labor  ;  many  are  delivered  spontaneously, 
or  by  the  aid  of  the  forceps.     Craniotomy  is  rarely  called  for. 

Ahlfeld  (Die  Entstehung  Steiss-  und  Gesichtslagen)  furnishes  twentj^-six 
cases  in  which  the  result  to  both  mother  and  child  is  given.  Fritsch  (Kliuik 
der  alltaglichen  geburtshiilflichen  Operationen,  p.  46)  gives  the  histories  of 
seven  cases,  and  Budix  (TMe  du  Foetus,  p.  53)  the  history  of  one  case.  In  the 
thirty-four  deliveries  there  were  two  maternal  deaths ;  in  one  of  the  fatal  cases 
coxalgic  oblique  pelvis  existed  as  a  complication.  In  the  other  the  brow  spon- 
taneously changed  into  a  face  presentation.  There  were  ten  spontaneous  deliv- 
eries, the  brow  presenting,  with  four  dead  children,  but  one  died  previous  to 
labor.  There  were  ten  cases  of  spontaneous  delivery  in  which  the  brow  during 
delivery  became  converted  into  either  a  face  or  vertex  presentation.  Of  these, 
one  child  died.  Fourteen  children  were  extracted  with  the  forceps,  nine  with 
the  brow  presenting,  of  which  two  were  dead,  one  from  prolapsed  funis,  and 

*  Recovery  of  both  mother  and  child.     (From  drawing  of  A.  II.  Fridenberg). 


ll^,;  LABOR. 

one  which  had  died  before  hibor;  five,  after  conversion  into  face  or  vertex  pres- 
entations,  with  no  deaths.  Thus,  of  the  thirty-four  children  there  were  seven 
deaths,  but  of  these  four  only  could  be  attributed  to  the  presentation. 

From  the  foregoing,  it  is  evident  that  the  duties  of  the  accoucheur, 
in  the  presence  of  brow  presentation,  should  be  confined  to  efforts  to 
direct  the  hibor  to  a  favorable  termination  by  one  of  the  paths  indi- 
cated by  Nature.  At  the  brint^^jrejviiiusto  engagement,  the  dip  of  the 
anterior  fontanelle  is  often  temporary,  in  many  cases  simply  signifying 
a  narrowing  in  the  upper  conjugate.  Version,  therefore,  so  frequently 
recommended  with  a  view  to  the  substitution  of  diameters  more  con- 
formable to  those  of  the  pelvis,  should  be  limited  to  cases  where  the 
head  is  retained  at  the  contracted  conjugate,  where  the  faulty  position 
is  due  to  cervical  stricture  (Bayer),  and  where  speedy  delivery  is  de- 
manded in  the  interest  of  either  mother  or  child. 

Manual  attempts  to  convert  a  brow  presentation  into  one  of  the 
face  or  vertex  possess  more  legitimate  claims  to  favor.  The  method  of 
Baudelocque  consists  in  seizing  the  head  with  the  entire  hand  intro- 
duced into  the  vagina,  lifting  it  to  the  brim,  and  then  drawing  the  oc- 
ciput downward  with  the  fingers  until  flexion  becomes  complete.  The 
procedure  was  bitterly  opposed  by  Chailly,*  who  urged  against  it,  in 
addition  to  the  frequency  of  failure,  the  dangers  of  uterine  rupture,  of 
prolapse  of  the  cord,  and  the  inconveniences  arising  from  the  early 
evacuation  of  the  amniotic  fluid.  There  is  no  question  of  success  by 
this  measure,  and,  if  care  is  exercised,  the  concurrent  risks  are  hardly 
sufficient  to  furnish  contra-indications.  At  any  rate,  it  would  be 
proper  to  make  the  attempt  when  brow  presentations  complicate  de- 
livery in  justo-minor  pelvis,  or  in  persistent  mento-posterior  positions, 
as  in  these  cases  craniotomy  is  the  only  alternative.  Complete  anaes- 
thesia facilitates  reduction.  While  elevating  the  head,  firm  counter- 
pressure  should  be  made  at  the  fundus  uteri. f 

Occasionally  the  conversion  of  the  brow  into  a  vertex  or  face  pres- 
entation may  be  effected  by  pressure  exerted  during  a  pain  upon  re- 
spectively the  occipital  or  frontal  extremity  of  the  head.  In  bringing 
down  the  vertex,  the  movement  should  be  aided  by  external  pressure 
made  with  the  disengaged  hand  above  the  brim  of  the  pelvis.  When 
a  face  presentation  is  desired,  the  woman  should  be  made  to  lie  during 
labor  upon  the  side  to  which  the  child's  abdomen  is  directed,  and  upon 
the  side  to  which  the  back  is  turned  when  the  descent  of  the  vertex  is 
aimed  at. 

SchatzJ  recommends,  with  the  view  to  the  production  of  a  face 

*  Chailly-Honork,  Traite  pratique  des  accouchements,  p.  783. 

f  Vide  Parry,  On  the  Use  of  the  Iland  to  correct  Unfavorable  Presentations, 
etc.,  Am.  Jour,  of  Obstet.,  vol.  viii,  p.  138. 

X  ScHATZ,  Die  Uinwandlung  von  Gesichtslage  zu  Hinterhauptslage,  etc.,  A  rch. 
f.  Gynaek.,  Bd.  v,  p.  338. 


MECHANISM    OF   LABOR.  1 9^ 

presentation,  the  introdiiction  of  two  fingers  into  the  child's  mouth, 
and  making  traction  on  the  superior  maxilla. 

When  the  head  shows  a  disposition  to  revert  to  its  original  position 
so  soon  as  pressure  or  traction  is  suspended,  the  forceps  should  be 
applied,  and  traction  made  in  such  a  manner  after  reposition  as  to 
hold  the  head  in  the  direction  sought  for. 

In  case  the  brow  presentation  is  irreducible,  the  labor  should  be 
allowed  to  continue  as  long  as  compatible  with  the  safety  of  the 
mother.  Owing  to  its  plasticity,  the  head  often  adapts  itself  in  the 
most  surprising  manner  to  the  unfavorable  diameters  of  the  pelvis,  so 
that,  even  when  spontaneous  delivery  fails  to  take  place,  the  forceps  be- 
come available.  In  mento-posterior  positions,  efforts  should  be  made 
with  the  fingers,  or  the  vectis,  to  rotate  the  chin  forward.  In  fixecl 
mento-posterior  positions,  the  use  of  the  forceps  is  impossible,  and  the 
conversion  of  the  brow  into  a  face  presentation  does  not  lessen  the 
mechanical  difficulties  of  delivery.  The  only  artifice  by  which  the 
life  of  the  child  can  be  saved  consists  in  bringing  down  the  occiput 
and  producing  a  vertex  presentation.  Failing  in  this  manoeuvre, 
craniotomy  becomes  inevitable.  In  all  cases  of  brow  jDreseutation,  if 
the  child  is  dead,  craniotomy  is  indicated  in  the  interest  of  the  mother. 

Breech  Presentations. 

In  breech  presentations  the  attitude  of  the  child  is  primarily  the 
same  as  in  those  of  the  vertex,  though,  owing  to  a  variety  of  causes,  such 
as  voluntary  or  reflex  movements  and  the  action  of  gravity,  especially 
after  rupture  of  the  membranes,  the  extremities  may  advance  in  front 
of  the  breech,  and  give  rise  secondarily  to  presentations  of  the  foot  or 
knee.  Sometimes  one  extremity  may  become  prolapsed,  while  the  other 
is  retained  in  its  normal  position  ;  again,  it  may  happen  that,  after  the 
rupture  of  the  membranes,  the  feet,  which  had  previously  been  in  close 
proximity  to  the  breech,  are  pushed  upward,  so  that  the  limbs  become 
extended  parallel  to  the  anterior  surface  of  the  child's  body.  None 
of  these  changes,  however,  materially  affect  the  mechanism  of  delivery. 

Pinard  *  found,  in  100,000  cases  of  confinement,  3,301  presentations 
by  the  breech,  or  in  the  proportion  of  one  to  thirty ;  but  excluding 
'premature  births,  the  proportion  was  reduced  to  one  in  sixty-two. 

Causes. — The  causes  of.  breech  .jpresentations  are  to  be  sought  for 
mainly  in  the  absence  of  the  conditions  which  ordinarily  determine 
the  presentations  of  the  head,  or  which  interfere  with  the  fixation  of 
the  foetus.  Thus,  the  production  of  breech  presentations  is  favored  by 
an  excess  of  amniotic  fluid,  by  lax  uterine  walls,  and  by  contractions  of 
the  pelvis.  They  are  more  common  in  multipara?  than  in  primiparae. 
Of  the  3,301  cases  collected  by  Pinard,  there  wereT,347  prrmiparse  and 
*  Tarxier  et  Chantretiil.  Traito  dv  larl  dos  ac.  p.  454. 


198 


LABOR. 


1,954  multipara?,  though  the  entire  number  was  nearly  equally  divided 
between  the  two  classes.*  Finally,  they  occur  with  greatest  frequency 
of  all  in  twin  pregnancies,  and  during  the  expulsion  of  premature  and 
dead  children.  Of  32,264  children  from  the  statistics  of  Hegar  and 
Spiegelberg,f  910  were  the  product  of  multiple  pregnancies,  and  659 


P^G.  117.— Preseutatiou  of  the  breech.     Left  dorso-anterior  pu.sitiou.     (Pinard.) 

were  premature  Of  the  former,  227,  or  25  per  cent,  and  of  the  latter, 
148,  or  224  per  cent,  were  delivered  by  the  breech,  though  we  have 
seen  that  the  ratio  of  breech  presentations  to  the  entire  number  of 
births  does  not  exceed  the  proportion  of  one  to  thirty. 

Diagnosis. — By  external  palpation  the  recognition  of  the  liead  at 
the  fundus  uteri  furnishes  the  chief  diagnostic  sign.  Upon  vaginal 
examination,  the  presenting  part,  as  in  face  presentations,  is  usually 
high  up,  and  reached  with  difficulty.  The  bag  of  membranes  is  apt^ 
to  be  of  large  size,  owing  to  the  imperfect  closure  of  the  lower  uterine 
segment  by  the  small  breech,  often  descending  through  the  canal, 
where  the  cervix  is  rigid,  in  the  form  of  an  elongated  pouch.  Through 
the  membranes,  upon  pressing  the  foetus  downward  during  the  inter- 
val between  the  pains,  the  breech  is  felt  as  a  soft,  irregular  body,  and 
with  care  it  is  possible  to  recognize  the  coccyx,  the  sacrum,  the  Jlia, 
and  sometimes  to  feel  tapping  movements  from  the  feet.  After 
rupture,  the  nates,  the  cleft  between  the  nates,  in  boys  the  scrotum, 

*  Vide  Tarnier  et  Chaxtreuil.  p.  4-5.5.  f  Spieoelbero,  loc.  fit.,  p.  171. 


MECHANISM   OF   LABOR.  ;^(^C) 

the  anus,'the  feet  when  accessible,  the  coccyx,  the  sacrum,  aud  the  ilia, 
furnish  the  necessary  data  for  an  exact  diagnosis.  The  pressure  of 
the  uterus  upon  the  breech  frequently  occasions  an  evacuation  of 
meconium.  The  latter  is  thick  and  consistent,  thereby  differing  from 
the  meconium  passed  in  vertex  cases  by  a  dying  foetus,  which  is 
ordinarily  thin  from  admixture  of  amniotic  fluid.  When  the  nates 
are  much  swollen  they  may  be  confounded  with  the  cheeks  in  a  face 
presentation — an  error,  however,  easy  to  avoid,  if  the  examination  be 
made  with  deliberation,  and  the  principaTpoints  of  difference  between 
breecli  and  face  already  given  {vide  "Face  Presentations,"  p.  191)  are 
borne  in  mind. 

The  foot,  as  compared  with  the  hand,  is  longer  and  narrower ;  tlie 
toes  are  shorter,  of  nearly  equal  length,  and  continuous  in  a  straight 
line  with  the  sole ;  the  ankle-joint  is  less  flexible  than  the  wrist,  and  is 
distinguished  by  the  malleoli  aud  the  pointed  heel.  As  the  outer  bor- 
der of  the  foot  is  thin  and  rounded,  while  the  inner  edge  is  thick  and 
hollowed,  it  becomes  possible  to  recognize  which  of  the  feet  is  under 
examination. 

The  knee  is  distinguished  from  the  elbow  by  its  larger  size,  by  the 
patella,  and  by  the  spine  of  the  tibia. 

The  Mechanism  of  Breech  Presentations. — The  position  in  breech 
presentations  is  defined  by  the  direction  of  the  back.  Thus,  we  have 
right  and  left  dorsal  positions.  Usually  the  hips  occupy  one  of  the 
oblique  diameters  of  the  pelvis.  According,  therefore,  as  the  back  is 
turned  anteriorly  or  posteriorly,  we  distinguish  right  and  left  dorso- 
anterior  and  dorso-posterior  positions. 

The  cervix  dilates  slowly,  especially  when  the  feet  are  in  close 
proximity  to  the  breech  and  increase  the  bulk  of  the  presenting  part. 
The  latter  is  pressed  downward  into  the  pelvis  until  the  perineal  floor 
is  reached.  Here,  owing  to  the  shortness  of  the  pubic  wall,  the  ante- 
rior hip  is  felt  with  great  distinctness,  while  the  cleft  of  the  nates  lies 
near  the  curved  sacrum.  These  anatomical  relations  give  rise  to  the 
impression  of  an  exaggerated  degree  of  lateral  obliquity.  At  the  peri- 
ngeuni  the  breech  glides  forward  and  rotates  upon  its  long  axis,  so  that 
the  bis-iliac  diameter  nearly  corresponds  to  the  lower  conjugate.  In 
the  movement  of  rotation,  it  is  always  the  anterior-lying  hip,  irrespect- 
ive of  the  position  of  the  trunk,  which  moves  to  the  front.  At  the 
outlet  one  hip  engages  beneath  the  arch  of  the  pubes,  the  other  rests 
upon  the  coccyx  and  perinaeum,  while  the  sacrum  is  directed  toward 
the  tuber  ischii.  As  thje_ shoulders  enter  the  pelvis  in  an  oblique 
diameter,  the  trunk  of  the  child  becomes  somewhat  twisted  by  the 
rotation  of  the  breech.  The  anterior  buttock  makes  its  appearance  at 
the  vulva,  while  the  posterior  distends  the  perinteum.  As  rotation  is 
rarely  complete,  the  forward  trochanter  usually  finds  its  point  of  sup- 
port against  the  nearest  iscKio-pubic  ramus.     During  the  advance  of 


200 


LABOR. 


the  breech  the  hmibar  region  undergoes  a  certain  amount  of  lateral 
flexion,  owing  to  the  forward  movement  imparted  to  the  posterior  hip 
by  the'  coccyx  and  elastic  perineum.  The  degree  of  flexion  is,  how- 
ever, limited  by  the  rigidity  of  the  lumbar  portion  of  the  vertebral 


Fig.  118.— Showing  lateral  inttexion  of  the  trunk  during  delivery  of  the  breech. 

column.  When  the  posterior  trochanter  reaches  the  commissure  of  the 
vulva,  the  perinaeum  retracts,  and  in  gliding  baciiward  directs  the 
breech  still  farther  to  the  front. 

After  delivery,  the  breech  rotates  into  the  oblique  diameter  it  had 
originally  occupied,  this  external  rotation  bringing  the  transverse 
diameter  of  the  hips  into  correspondence  with  that  of  the  shoulders. 
The  uterine  contractions  continuing,  the  abdomen  and  base  of  the 
thorax  slowly  make  their  appearance  ;  the  thighs  are  then  delivered, 
and  the  arms,  folded  upon  the  upper  portion  of  the  thorax,  emerge 
from  the  vulva.  The  shoulders,  which  enter  the  pelvis  in  an  oblique 
diameter,  are  delivered  in  the  conjugate,  the  anterior  shoulder  resting 
beneath  the  pubic  arch,  while  the  posterior  shoulder  sweeps  over  the 
perinaeum. 

The  head  enters  the  pelvis  in  an  oblique  diameter,  with  the  chin 
flexed  upon  the  thorax.  The  expulsive  efforts  as  the  chin  reaches  the 
perineum  are  followed  by  the  rotation  of  the  occiput  to  the  pubes,  and 
of  the  face  into  the  hollow  of  the  sacrum.  At  the  outlet  the  neck  is 
supported  by  the  arch  of  the  pubes,  the  face  rests  upon  the  perinteum, 
and  the  large  fontanelle  is  felt  at  the  coccyx.  Under  the  influence  of 
pressure  from  the  abdomen,  the  brow  sinks  deeper  and  deeper,  and  is 


MECHANISM   OF   LABOR. 


201 


pushed  by  the  soft  parts  of  the  pelvic  floor  still  closer  to  the  thorax. 
The  occiput  then  revolves  beneath  the  pubic  arch,  and  the  chin,  the 
moutb,  the  nose,  the  brow,  the  large  fontanelle,  and  finally  the  occiput, 
appear  in  succession  at  the  commissure  of  the  vulva. 

Irregularities  in  the  Mechanism  of  Breech  Presentations.— Though 
it  is  by  no  means  rare  for  the  breech  to  enter  the  pelvis  with  the 
sacrum  turned  to  the  sacro-iliac  synchondrosis,  the  rotation,  begun 
with  the  passage  of  the  hips  through  the  vulva,  usually  continues  in 
the  same  direction  until  the  back  revolves  to  the  front ;  or,  after  a  first 
slight  retrograde  movement,  the  rotation  forward  takes  place  as  the 
shoulders  engage  at  the  outlet.  Still,  cases  do  sometimes  occur  in 
which  the  back  remains. posterior  during  the  whole  period  occupied  by 
the  expulsion  of  the  trunk,  and  in  which,  consequently,  the  head  enters 
the  pelvis  with  the  face  directed  to  the  pubes.  Even  here,  however, 
it  is  viery  common  for  the  occiput  to  eventually  rotate  forward,  and  for 
delivery  to  follow  in  the  ordinary  manner.     Should,  on  the  contrary. 


Fig.  119.— Exit  of  head  in  breech  presentations.    Face  covered  by  perinaeum. 
iFarabceuf  and  Varnier.i 


the  occiput  remain  in  the  hollow  of  the  sacrum,  spontaneous  delivery 
may  occur  in  either  of  two  ways:  1.  When  no  tractions  have  been 
made  upon  the  extremities,  the  head  reaches  the  outlet  with  the  chin 
well  flexed,  the  neck  resting  upon  the  commissure  of  the  vulva,  and  the 
brow  braced  against  the  arch  of  the  pubes.  The  birth  of  the  head  is 
then  accomplished,  as  the  neck  pushes  back  the  perinaeum,  by  the  suc- 
cessive descent  of  the  face,  the  cranial  vault,  and  the  occiput.  With  a 
rigid  perineum,  or  an  immovable  coccyx,  owing  to  the  considerable 
degree  of  flexion  which  this  movement  necessitates,  unaided  delivery 


202 


LABOR. 


may  be  rendered  impossible.  2.  If,  during  the  tran.sit  of  the  head 
through  the  pelvis,  extension  occurs,  the  chin  may  be  arrested  at  or 
above  the  symphysis  pubis.  In  this  position  pressure  from  above 
pushes  back  the  brow,  so  that  the  face  looks  upward,  and  the  occiput 
is  turned  to  the  bottom  of  the  pelvic  excavation.  During  delivery  the 
occiput  glides  over  the  perinteum  to  the  fourchette,  and  the  small  fon- 


FiG.  120.— Exit  of  head  in  breceli  presentations.     Face  has  emerged  from  the  perinaeum. 


tanelle,  the  cranial  vault,  and  the  face  escajie  in  succession  through  the 
vulva.  It  is  only  possible  for  this  method  of  delivery  to  take  place 
spontaneously  when  either  the  head  is  small  or  the  pelvis  roomy,  and 
the  soft  parts  are  devoid  of  rigidity.  In  artificial  extraction  of  the 
head,  it  is  proper  to  bear  in  mind  and  to  imitate  the  natural  order  in 
expulsion. 

In  presentations  of  the  foot  and  knee,  the  breech,  if  of  small  size, 
may  pass  the  vulva  in  an  oblique  or  transverse  diameter,  rotation  fol- 
lowing later  during  the  passage  of  the  trunk. 

Excessive  rotation  is  not  imcommon,  both  head  and  trunk  some- 
times describing  a  half-circle.  This  occurrence  is  most  frequently 
observed  in  cases  where  the  posterior  extremity  presents,  while  the 
anterior  buttock  is  caught  above  the  pubic  wall,  the  prolapsed  limb 
then  rotating,  as  a  rule,  to  the  front.* 

The  Conflguration  of  the  Foetus  in  Breech  Deliveries.— During  the 
descent  of  the  child  through  the  genital  canal,  more  or  less  swelling  is 
developed  upon  that  portion  of  the  presenting  part  which  is  subjected 
to  diminished  pressure.     This  swelling  varies,  according  to  the  dura- 

*  Vide  KtisTXER.  Die  Steiss-  uiul  Fusslageii.  p.  21. 


MECHANISM    UK    L.\liUK. 


203 


Idl. ^Showing  shape  of  head  iu  brt 
(Budin.) 


^(•\\  presentations. 


tiou  of  labor,  from  a  slight  cedeina  to  a  large,  intensely  discolored  tumor, 
it  is  usually  seated  upon  the  anterior  buttock,  but  often  invades  the 
genital  organs,  especially  the  scrotum,  which  at  birth  may  present  a 
bluish-black  color,  and  be 

of  double  the  usual  size.  ^ 

The  extremities,  when 
near  the  breech,  may  also 
show  signs  of  discolor- 
ation. 

The  head  has  usually 
a  characteristic  round 
shape.  This  is  due,  ac- 
cording to  Spiegelberg,* 
to  the  pressure  exerted 
by  the  genital  canal  upon 
the  circumference  of  the 
head,  while  at  the  same 
time,  with  the  absence  of 
pressure  from  above,  there 
is  produced  an  increase 
in    tlie   convexity  of   the 

cranial  vault.  Two  cases  reported  by  Hecker,f  in  which  the  length 
of  the  occiput  was  comparable  to  that  found  in  face  presentations, 
show,  however,  that  the  original  shape  of  the  head  counts  for  some- 
thing in  the  appearances  presented  after  delivery. 

Prognosis. — As  regards  the  mother,  the  prognosis  in  uncomplicated 
cases  does  not  differ  materially  from  that  of  vertex  cases.  Where 
manual  extraction  becomes  necessary,  there  is  always,  however,  increased 
danger  of  lacerating — 1,  the  cervix  ;  2,  the  perineum. 

Lacerations  are  apt  to  follow  attempts  to  drag  the  after-coming 
head  through  an  imperfectly  dilated  cervix.  The  prognosis  is  more 
favorable,  therefore,  in  cases  where  the  membranes  do  not  rupture  until 
after  dilatation  is  completed.  It  is  also  better  in  pelvic  presentations, 
where  the  bulk  of  the  breech  is  increased  by  the  addition  of  the  ex- 
tremities. In  footling  cases,  when  the  membranes  rupture  prematurely, 
the  smaller  size  of  the  pelvis  and  its  rapid  descent  through  the  cervix 
imperfectly  prepare  the  way  for  the  subsequent  passage  of  the  head. 
A  stricture  is  therefore  liable  to  form  abont  the  neck  of  the  child, 
and,  as  the  spasm  does  not  yield  to  force,  the  result  of  violent  tractions 
*is  to  sacrifice  the  integrity  of  the  cervix,  the  extent  of  the  laceration 
being  proportioned  to  the  power  exerted. 

Lacerations  of  the  perinaeum  occur  where  with  rigidity  of  the 
tissues   it   becomes   necessary   to   introduce  the   hand   to  release    the 


necessary 

*  Spiegelbeko.  foe.  ri(.,  p.  ITfi. 

f  Hecker.  Ai-cli.  f.  (ivnaek..  Bd.  .Ki.  p. 


348. 


20* 


LABOR. 


arms,  or    the   interest  of  the  child  demands  the  speedy  delivery  of 

the  head. 

The.  prognosis  for  the  child  is,  on  the  other  hand,  extremely  un- 
favorable. According  to  the  statistics  of  Dubois,*  the  mortality  in  full- 
term  children  is  as  one  to  eleven,  while  in  vertex  presentations  the  pro- 
portion is  as  one  to  fifty.  The  chief  cjluse  of  this  large  death-rate  is 
the  pressure  to  which  the  cord  is  subjected  between  the  child  and  the 
surface  of  the  utero-vaginal  canal,  especially  after  the  navel  appears  at 
the  vulva.  The  pressure  is  exerted  principally  at  the  orifices  of  the 
uterus  and  the  vagina,  and  is  raised  to  the  point  of  greatest  danger 
after  the  head  has  become  engaged  in  the  pelvis.  Other  sources  of  peril 
arise  from  prolapse  of  the  funis  and  the  coiling  of  the  latter  around 
the  body  of  the  child,  and  from  the  complete  escape  of  the  aniniotie 
fluid  in  premature  rupture  of  the  membranes. 

Treatment. — Early  in  labor,  with  the  membranes  intact,  it  is  desir- 
able, in  consideration  of  the  unfavorable  prognosis  for  the  child,  to  try 
and  perform  cephalic  version  by  external  manipulations.  In  case  of 
failure  to  bring  down  the  head,  care  should  be  taken  to  preserve  the 
membranes  until  dilatation  is  completed.  To  this  end  unnecessary 
examinations  should  be  avoided  ;  the  patient  should  be  placed  upon  her 
side,  and  cautioned  not  to  strain ;  and  when  the  membranes  tend  to 
form  an  elongated  pouch,  counter-pressure  may  be  employed  by  means 
of  a  moderately  distended  Barnes's  dilator  introduced  into  the  vagina. 
After  rupture  of  the  membranes  it  is  best  to  remain  passive.  In  the 
interest  of  the  child,  it  is  desirable  that  the  expulsion  of  the  trunk 
should  take  place  slowly.  Bringing  down  an  extremity,  as  a  prophy- 
lactic measure  in  order  to  secure  a  good  handle  in  case  of  subsequent 
delay,  is  a  questionable  procedure.  By  this  manceuvre  a  path  is  opened 
for  the  descent  of  the  cord,  and  the  mechanism  of  delivery  is  disturbed. 
When  the  hips  appear  at  the  vulva,  the  attending  physician  should  be 
ready  to  extract  in  case  of  emergency.  The  patient  should,  therefore, 
if  lying  upon  the  left  side,  be  brought  near  the  edge  of  the  bed;  if 
upon  the  back,  she  should  be  placed  across  the  bed,  with  the  hips  well 
over  the  edge.  She  should  be  instructed  to  bear  down  during  the 
pains.  The  lateral  flexion  of  the  lumbar  portion  of  the  trunk  should 
be  sustained  by  the  hand  applied  to  the  perineum.  The  trunk,  as  it 
advances  through  the  vulva,  should  be  wrapped  in  a  warm  cloth  and 
raised  upward.  When  the  cord  appears,  it  should  be  drawn  gently 
downward  in  the  direction  of  one  of  the  recesses  to  the  side  of  the 
promontory ;  in  case  the  cord  passes  between  the  thighs  of  the  child,  \\ 
should  be  released  by  slipping  it  over  one  hip.  From  this  time  on  the 
pulsations  of  the  cord  should  be  carefully  watched,  and,  in  case  of  fail- 
ing strength,  extraction  should  be  resorted  to. 

With  one  hand  the  physician  now  supports  the  body  of  the  child, 
*  Dubois,  Mem.  de  I'Acad.  Roy  de  Med.,  vol.  iii,  p.  450. 


CONDUCT  OF  NORMAL  LABOR.  2l)5 

while  with  the  other  he  should  make  sustained  and  gradually  increas- 
ing pressure  upon  the  fundus  uteri.  The  patient  should  be  exhorted 
to  strain,  and  bring  into  play  all  the  auxiliary  muscles  concerned  in 
expulsion.  During  the  passage  of  the  arms,  the  lateral  flexion  of  the 
body  should  be  promoted  by  raising  the  hips  and  supporting  the  peri- 
iin?um.  After  the  engagement  of  the  head,  it  is  desirable,  if  possible, 
to  commit  to  the  hands  of  a  skilled  assistant  the  maintenance  of  the 
supra-pubic  pressure.  When  the  face  reaches  the  coccyx,  the  physician 
should  raise  the  body  of  the  child  toward  the  abdomen  of  the  mother. 
By  this  manoeuvre  the  occiput  is  pushed  upward  by  the  pubic  Avail,  and 
the  chin  brought  forward  to  the  vulva.  The  delivery  of  the  head  is 
then  speedily  accomplished  by  pressing  the  forehead  forward  with  two 
lingers  applied  to  the  perinaeum  in  front  of  the  coccyx,  or  introduced 
into  the  rectum.  By  then  keeping  the  head  jflexed,  lacerations  of  the 
perinaeum  are  best  avoided. 

When  the  occiput  is  turned  posteriorly,  the  body  should  be  raised 
if  the  chin  is  arrested  at  the  symphysis,  and  depressed  when  flexion  is 
complete. 


CHAPTER  XI. 

CONDUCT  OF  NORMAL  LABOR. 

Preliminary  preparations. — Examination  of  the  patient. — Management  of  the  first 
stage. — Management  of  the  second  stage. — Preservation  of  the  perintBum. — 
Delivery  of  the  shoulders. — Tying  the  cord. — Third  or  placental  stage. — Care 
of  patient  after  delivery. — Treatment  of  perineal  lacerations. — AniBsthetics  in 
midwifery. 

It  is  hardly  an  exaggeration  to  state  that  the  greater  proportion  of 
the  sins  of  midwifery  practice  are  committed  in  the  management  of 
normal  labors.  It  is  equally  easy  to  fall  into  errors  of  commission  and 
errors  of  omission.  It  is  as  necessary  to  know  when  to  abstain  as  when 
to  interfere.  It  is  an  old  but  always  good  rule,  not  to  meddle  with  the 
physiological  performance  of  a  function ;  but  the  rule,  when  applied  to 
obstetrics,  presupposes  a  thorough  familiarity  with  the  physiological 
processes  of  childbirth,  and  the  contingencies  to  which  women  in  par- 
turition are  exposed.  There  is  no  sense  in  reposing  a  blind,  unreason- 
ing confidence  in  the  powers  of  Nature.  Indeed,  legitimate  grounds 
for  interference  are  liable  to  arise  in  the  simplest  labors.  The  attitude 
of  the  medical  attendant  should  be  one  of  watchful  expectancy.  He 
should  be  ready,  if  needful,  to  assuage  pain,  to  forestall  dangers,  and  to 
limit  the  duration  of  sufl'ering. 

Preliminary  Preparations.— When  summoned  to  a  patient,  the  phy- 
sician should  ao  armed  to  meet  the  sudden  emergencies  of  obstetrical 


^,,„]  LABOR. 

practice.  His  armamentarium  slioulcl  include  a  silver  catheter,  an 
English  catheter  of  small  size  (No.  7)  for  use  in  asjihyxia  of  the  new- 
born child,  a  pair  of  forceps,  needles  and  needle-holder,  and  silk  or 
wire  for  sutures,  a  Davidson  syringe,  a  set  of  Barnes's  dilators,  and  a 
hypodermic  syringe.  He  should  go  provided  with  chloroform,  Ma- 
gendie's  solution  of  morphia,  ergot,  the  perchloride  or  persulphate  of 
iron,  carbolic  acid,  powders  or  tablets  of  corrosive  sublimate,  and  a  small 
vial  of  sulphuric  ether.  At  the  house,  ice,  brandy  or  whisky,  hot 
and  cold  water,  a  new  English  gum  catheter  (No.  10),  and  a  fountain 
syringe,  should  be  had  in  readiness. 

As  it  is  not  uncommon  for  women,  especially  among  the  poorer 
classes,  to  test  the  experience  of  young  physicians  by  asking  details 
relative  to  the  arrangement  of  the  bed  upon  which  the  confinement  is 
to  take  place,  it  is  trusted,  that  a  few  words  upon  the  subject  will  not 
be  regarded  as  entirely  superfluous. 

The  bedstead  should  not  be  too  low.  If  against  the  wall,  it 
should  be  moved  out,  so  as  to  allow  easy  access  from  both  sides. 
The  bedding  should  consist  of  a  hair  mattress  or  of  a  straw  i)aillasse. 
Feather-beds  are  an  abomination.  Over  that  portion  of  the  mat- 
tress upon  which  the  woman  expects  to  lie,  a  rubber-cloth  or  other 
impervious  material  should  be  sjiread.  Next  to  the  water-proof, 
nurses  usually  lay  a  folded  woolen  comforter  or  blanket,  to  absorb 
the  fluid  discharges.  The  whole  is  then  covered  smoothly  w^ith  a 
sheet,  and  a  second  sheet,  folded  in  several  thicknesses,  is  laid  beneath 
the  hips  of  the  patient.  All  these  preparations  are  designed  to  limit 
the  soiling  of  the  bedding  to  a  circumscribed  space,  and  to  facilitate 
the  removal  of  the  discharges  after  the  termination  of  the  delivery. 
The  sheets  and  articles  in  contact  with  the  patient  should  be  freshly 
washed.  Soiled  linen  is  incompatible  with  the  requirements  of  aseptic 
labor. 

Examination  of  the  Patient. — The  first  duty  which  devolves  upon 
the  physician  in  the  lying-in  chamber  is  to  examine  his  patient,  and  to 
inform  the  family  if  "  all  is  right  " — i.  e.,  whether  the  head  presents, 
and  no  unusual  obstacle  to  delivery  exists.  It  is  a  good  plan  at  the 
outset  to  map  out  the  foetus  through  the  abdominal  and  uterine  walls, 
as  by  palpation  alone  it  is  usually  possible  to  determine  the  dorsum  of 
the  child,  the  presentation  at  the  pelvic  brim,  the  direction  of  the 
feet,  and  the  presence  or  absence  of  fetal  movements.  So,  too,  by  ex- 
ternal methods  we  are  enabled  to  make  out  the  size  and  shape  of  the 
uterus,  the  existence  of  hydramnion,  the  presence  of  twins,  or  of  com- 
plicating tumors.  The  strength  and  frequency  of  the  fetal  heart- 
sounds  should  be  ascertained  by  auscultation.  Inspection  and  palpa- 
tion of  the  pelvis  suffice  to  make  evident  grosser  varieties  of  deformity. 
Nearly  everything  in  the  way  of  essential  information  is  obtainable 
without  resorting  to  an  internal  examiuation — a  fact  of  no  mean  im 


CONDUCT   OF  NORMAL   LABOR.  207 

portaiice  wheu  a  physician  fiuds  liiiuself  obliged  to  conduct  a  case  of 
labor  when  fresh  from  contact  with  materials  capable  of  conveying 
infection. 

Before  proceeding  to  a  vaginal  examination  the  physician  should 
scrupulously  clean  the  nails,  the  hands,  and  forearms  with  soap  and 
water,  then  wash  them  with  pure  water,  and  afterward  immerse  them 
for  several  minutes  in  a  solution  of  corrosive  sublimate  in  the  propor- 
tion of  one  to  a  thousand.  Similar  precautions  should  be  taken  by  the 
nurse ;  and  in  the  same  way  the  external  parts,  the  perinaium,  the 
mons  veneris,  the  inner  surface  of  the  thighs,  and  the  abdomen  of  the 
patient,  should  be  freed  from  impurities.  Soap  and  water  should  be 
preferred  as  a  lubricant  for  the  fingers.  Under  normal  conditions  the 
vagina  is  to  be  regarded  as  aseptic.  Douching,  therefore,  with  strong 
solutions  of  carbolic  acid  or  corrosive  sublimate  is  not  indicated  as  a 
prophylactic  measure. 

The  internal  examination  should  take  cognizance  of  the  condition 
of  the  vulva  and  perineum,  the  state  of  the  rectum  and  bladder,  the 
length  of  the  vagina,  the  degree  of  dilatation  and  softening  of  the 
cervix,  the  amount  of  cervical  and  vaginal  secretion,  the  hardness  of 
the  child's  head,  the  dimensions  of  the  pelvis,  and,  if  the  membranes 
are  not  ruptured,  the  quantity  of  amniotic  fluid.  It  is  customary  to 
begin  the  examination  during  an  interval  between  the  pains,  but  it  is 
often  convenient  to  continue  the  investigation  during  the  pains,  in  or- 
der to  judge  of  their  eflBcacy  and  character. 

The  history  of  the  case  should  embrace  the  length  of  previous 
labors,  the  health  during  pregnancy,  the  number  of  times  the  woman 
has  been  pregnant,  and  Avhether  in  the  present  instance  she  has  ad- 
vanced to  full  time.  Inquiries  should  be  made  as  to  when  the  labor- 
pains  commenced,  as  to  their  frequency  and  situation,  and  if  the  mem- 
branes have  ruj)tured. 

After  the  examination  of  the  patient  is  ended,  the  physician  is  ex- 
pected to  express  an  opinion  as  to  the  probable  duration  of  the  labor. 
It  is,  however,  necessary  for  the  responses  upon  this  point  to  be 
guarded  and  Delphic.  In  general  terms,  when  the  pelvis  is  normal, 
the  head  well  flexed,  the  vagina  short,  and  the  cervix  and  perinai-um 
are  dilatable,  an  easy  and  rapid  labor  is  to  be  anticipated ;  while,  ;jpr 
contra,  with  a  small  pelvis,  tardy  flexion,  a  long  vagina,  and  rigidity  of 
the  uterine  and  perineal  orifices,  a  tedious  period  of  waiting  is  to  be 
assumed.  Of  course,  too,  labor  is,  as  a  rule,  much  longer  in  primi- 
parae  than  in  women  who  have  previously  borne  children.  Moreover, 
with  few  exceptions,  the  result  depends  in  a  special  degree  upon  the 
energy  and  persistence  of  the  pains.  The  latter,  however,  represent 
always  the  uncertain  element  in  the  calculation.  If  the  pains  are 
good,  therefore,  the  reservation  should  be  made  that,  for  a  short  labor, 
they  must  continue  as  at  the  beginning;  while,  if  weak  and  powerless, 


208 


LABOR. 


it  should  be  stated  tliat  better  pains  will  be  needed  to  bring  the  labor 
to  a  speedy  conclusion. 

Management  of  the  Fikst  Stage  of  Labok. 

The  duties  of  the  physician  during  the  first  stage  of  labor  are,  in 
normal  cases,  extremely  simple.  He  sliould  from  time  to  time,  say  at 
hourly  intervals,  repeat  the  examination  with  the  precautions  already 
indicated,  with  a  view  to  inform  himself  of  the  progress  of  dilatation. 
He  should  caution  his  patient  to  pass  her  urine  frequently.  In  case  of 
retention,  he  should  draw  the  water  Avitli  a  catheter.  When  the  head 
is  low  down,  the  urethra  often  follows  its  convexity.  The  introduction 
of  the  straight  female  catheter  may  then  be  extremely  difficult.  Many 
recommend  in  such  cases  a  silver  male  catheter  to  whicli  a  suitable 
curve  has  been  giveu.  I  use  by  preference  the  English  flexible  cathe- 
ter, which  is  passed  easily,  provided  the  end  is  guided  by  the  index- 
finger,  through  the  anterior  vaginal  wall,  to  the  point  of  contact  be- 
tween the  head  and  the  symphysis  pubis.  A  flattening  of  the  tube  by 
pressure  to  an  extent  causing  obliteration  is  not  likely  to  take  plaCe. 
The  catheter  should  be  a  new  one,  of  about  the  No.  10  size. 

In  many  instances  certain  hindrances  to  labor  are  remediable  by  postural 
methods.  Thus,  in  the  half-sitting  posture,  with  the  shoulders  raised,  the  axis 
of  the  uterus  assumes  a  direction  vertical  to  the  pelvic  brim.  This  attitude 
contributes  to  bring  the  weight  of  the  ovum  to  bear  directly  upon  the  lower 
segment,  and  tends  to  correct  presentations  of  the  posterior  parietal  bone.  The 
direction  of  the  head  to  the  sacrum  in  pendulous  abdomen  is  to  be  remedied 
by  the  complete  dorsal  decubitus.  Marked  lateral  deviations  of  the  cervix  are 
to  be  corrected  by  placing  the  patient  upon  the  opposite  side. 

If  at  the  time  of  exami)uition  the  rectum  is  found  clogged  with 
faeces,  an  enema  should  be  ordered.  A  disposition  on  the  part  of  the 
patient  to  bear  down  during  the  first  stage  of  labor  should  be  discour- 
aged, as  wasting  her  strengtli  without  possessing  any  counterbahmcing 
utility.  The  patient  sliould  be  encouraged  not  to  take  to  bed  at  the 
outset  of  labor.  In  the  upright  or  sitting  posture  gravity  aids  the 
fixation  of  the  head  and  promotes  passive  hyperoeraia  and  dilatation  of 
the  cervix. 

As  the  end  of  the  first  stage  approaches,  however,  the  woman  should 
undress  and  lie  down,  as  the  pains  after  rupture  usually  follow  one 
another  with  rapidity,  and  make  locomotion  difficult.  To  avoid  soil- 
ing, the  night-dress  should  be  drawn  well  up  under  the  arms.  Tidy 
nurses  pin  a  folded  sheet  around  the  hips  of  their  patients,  to  arrest 
the  soaking  of  fluids  upward. 

Euptare  of  the  membranes  is  ordinarily  a  spontaneous  act.  Yet 
often  enough  something  may  be  done  in  the  way  of  shortening  labor 
by  puncturing  the  membranes  so  soon  as  cervical  dilatation  is  complete 


CO.NDUCT   OF  NORMAL  LABOR. 


209 


They  have  then  fulfilled  their  i^hysiological  mission,  and  their  persist- 
ence simply  retards  the  advance  of  the  child's  head.  Artificial  rupt- 
ure is  easily  effected  by  means  of  a  straightened  hairpin  passed  in  the 
groove  between  the  index  and  middle  fingers  of  the  examining  hand  to 
the  amniotic  pouch.  The  puncture  should  be  made  during  a  pain,  at 
a  time  Avlien  the  membranes  are  tense  and  separated  from  the  scalp  by 
a  deep  layer  of  fluid. 

f 

Makagemeis^  of  the  Second  Stage  of  Labor. 

The  management  of  the  second  stage  of  labor  calls  for  considerable 
tact  on  the  part  of  the  medical  attendant.  It  is  incumbent  upon  him 
to  make  examinations  from  time  to  time  to  determine  the  degree  of 
rapidity  with  which  the  descent  of  the  head  takes  place.  So  long  as 
the  advance  is  regular,  he  should  abstain  from  interference.  Should 
the  pains  slacken,  however,  he  should  not  allow  the  duration  of  the 
second  stage  to  exceed  the  physiological  limits.  It  is  not  easy  to  de- 
fine exactly  what  is  implied  in  the  expression,  "physiological  limits." 
As  a  rule,  a  very  rapid  second  stage  is  not  physiological,  as  it  endangers 
the  integrity  of  the  vagina  and  perinaeum,  and  predisposes  to  post- 
partum ha3morrhage.  Still,  now  and  then  labor  is  ended  by  a  single 
pain  after  rupture  of  the  membranes,  without  detriment  to  the  mother. 
Of  course,  such  cases  are  extremely  uncommon  in  primiparaj.  They 
require  an  unusually  distensible  condition  of  the  soft  parts  and  an  ex- 
traordinary degree  of  resiliency  in  the  uterus.  On  the  other  hand, 
pressure  of  the  head,  after  its  descent  into  the  pelvic  cavity,  leads,  if 
too  long  continued,  to  pathological  changes  in  the  tissues  of  the  canal 
and  of  the  outlet.  It  is  usual,  therefore,  unless  the  head  is  small  or 
the  pelvis  roomy,  to  use  the  resources  of  art  to  terminate  labor  when 
the  head  remains  stationary  at  the  perineal  floor  after  two  hours  of 
effort.  It  is  desirable,  therefore,  when  the  pains  are  weak  and  ineffect- 
ive, to  utilize  all  the  simple  adjuvants  which  experience  has  shown  to 
possess  real  efficacy  in  increasing  the  activity  of  labor. 

Changes  of  posture  increase  the  power  of  the  pains  temporarily. 
When  head-flexion  is  incomplete,  it  has  been  recommended  to  place 
the  patient  upon  the  side  toward  which  the  occiput  is  turned.  Others, 
again,  claim  that  the  descent  of  the  occiput  is  best  effected  by  placing 
the  mother  upon  the  side  toward  which  the  child's  forehead  is  directed. 
In  point  of  fact,  either  posture  frequently  leads  to  the  desired  result, 
simply  because  the  change  from  the  dorsal  to  the  lateral  position  is  apt 
to  be  followed  by  a  temporary  addition  to  the  uterine  force.* 

In  many  women,  owing  to  defective  innervation  or  to  insufficient 
development  of  the  muscular  structures  of  the  uterus,  it  is  of  great 
moment  that  the  expulsion  of  the  child  be  aided  by  the  voluntary 

*  Lahs,  Die  Theorie  der  Geburt,  Bonn,  1877,  p.  237. 
14 


21Q  LABOR. 

pressure  of  the  abdominal  walls.  To  be  sure,  in  most  cases  the  reflex 
impulse  to  bear  down  is  imperative ;  but  in  otliers,  where  the  impulse 
is  feeble  or  held  in  abeyance  by  the  dread  of  the  patient  lest  she  in- 
crease her  sufferings,  it  becomes  the  duty  of  the  physician,  in  tardy 
labors,  to  see  to  it  that  all  the  auxiliary  forces  are  brought  into  play. 
To  this  end  he  should  instruct  his  patient  to  fix  her  pelvis,  either  by 
pressing  her  feet  against  the  foot  board  of  the  bed,  or  by  drawing  up 
her  knees  and  resting  them  against  an  assistant,  who  assumes  the 
position  best  adapted  to  furnish  the  requisite  support.  Then  the 
nurse,  or  other  suitable  person,  should  grasp  the  woman's  hands,  so 
as  to  enable  her  to  fix  her  thorax  and  to  bring  all  the  expiratory 
muscles  into  full  exercise.  Often,  when  the  agony  is  intense  the 
patient  can  be  induced  to  strain  with  her  pains,  if  her  sufferings 
are  first  dulled  by  small  doses  of  chloroform.  When  the  head  is  on 
the  perinaium,  the  physician  may  further  expulsion  by  rubbing  the 
abdomen  to  excite  pains,  and  by  pressing  upon  the  breech  through 
the  fundus. 

During  the  second  stage  the  patient's  posture  should  be  left  in 
general  to  her  own  volition.  The  physician  should  accustom  himself 
to  conduct  labor  with  equal  facility,  no  matter  whether  the  woman  lies 
upon  her  side  or  upon  her  back.  The  left  lateral  j)osition,  affected 
by  English  accoucheurs,  is  very  convenient  at  the  timi;  of  delivery,  es- 
pecially when  there  is  occasion  to  support  the  perinajum,  and  where, 
owing  to  the  flatness  of  the  nates,  the  vulya  is  scarcely  raised  in  the 
dorsal  posture  above  the  level  of  the  bedding. 

The  Pkeservatiox  of  the  Perin.eum. 

By  far  the  most  delicate  task  which  the  physician  has  to  fulfill 
toward  his  patient  in  the  expulsion  stage  consists  in  so  regulating  tlie 
exit  of  the  child's  head  as  best  to  avoid  perineal  lacerations.  It  is 
needless  to  state  that  such  lacerations,  unless  of  slight  extent,  entail 
upon  women  a  variable  degree  of  subsequent  discomfort  and  suffering. 
When  the  perinaeum  is  examined  with  care  after  labor — a  practice  which 
should  be  invariable  with  a  conscientious  attendant — the  frequent  oc- 
currence of  more  or  less  extensive  rupture  of  its  tissues  is  a  matter  of 
easy  confirmation.  Statistics  of  their  frequency  are  of  little  value, 
much  depending  upon  individual  skill  in  management.  Olshausen  * 
reports,  as  the  result  of  the  preventive  measures  adopted  at  the  clinic 
in  Halle,  during  a  period  of  ten  years,  21-1  per  cent  of  perineal  in- 
juries in  primiparse  and  4-7  per  cent  in  multiparas.  These  percent- 
ages did  not  include  slight  tears  confined  to  the  fraenulum.  He  regards 
15  per  cent  as  not  too  high  an  estimate  for  the  absolutely  unavoidable 

*  Olshausen,  Ueber  Dammverletzung  und  Dammschutz,  Volkmann's  Saminl. 
klin.  Vortr.,  No.  41,  p.  360. 


CONDUCT  OF  NORMAL  LABOR.  211 

lacerations,  due  to  defective  distensibility  of  the  perinaeum,  and  to  the 
disproportionate  size  of  the  child's  head. 

The  aim  of  prophylactic  measures  should  be  to  develop  the  elas- 
ticity of  the  soft  parts  to  the  fullest  practicable  extent,  and  to  cause 
the  head  to  pass  through  the  distended  orifice  of  the  vulva  by  its  small- 
est diameters.  Preliminary  softening  of  the  perinaeum  is  best  accom- 
plished by  the  continuous  but  not  too  rapid  descent  of  the  presenting 
part.  The  relaxation,  as  a  rule,  begins  earlier  and  is  more  complete 
in  multiparas  than  in  primipar*.  In  a  few  cases  the  soft  parts  will 
already  have  ceased,  by  the  end  of  the  first  stage  of  labor,  to  offer  any 
effective  barrier  to  delivery.  The  distensibility  of  the  soft  parts  may 
be  fairly  inferred  from  the  presence  of  a  copious  discharge  of  glairy 
mucus. 

When  rupture  takes  place,  the  vaginal  mucous  membrane  is  the 
first  structure  to  give  way.  In  the  ordinary  form  the  perineal  body 
tears  from  the  commissure  backward  to  the  rectum.  In  rare  cases  a 
central  perforation  may  result,  and  the  child  be  expelled  through  a 
rent  situated  between  the  vulva  and  the  anus. 

When  the  head  begins  to  make  the  perinaeum  bulge  the  physician 
should  be  on  the  alert,  and  inform  himself  during  each  contraction  of 
the  strain  to  which  the  parts  are  subjected.  At  first  it  is  only  neces- 
sary to  rest  the  hand  lightly  upon  the  perinasum.  Direct  pressure  is 
to  be  avoided,  except  when  the  perinaeum  is  stretched  to  a  membranous 
thinness,  and  the  danger  of  central  perforation  threatens.  As  the  head 
begins  to  distend  the  vulva,  the  tension  at  the  fr^enulum  should  be 
carefully  gauged  by  a  finger  introduced  between  the  labia.  Measures 
to  avert  ru2:>ture  may  be  classified  under  three  headings,  viz. : 

1.  Those  designed  to  check  the  exit  of  the  head  before  the  fullest 
expansion  has  been  secured,  and  to  prevent  expulsion  during  the  acme 
of  a  pain,  when  the  borders  of  the  orifice  are  most  rigid. 

2.  Measures  which  impart  an  upward  movement  to  the  head,  with 
a  view  of  making  all  unoccupied  space  beneath  the  arch  of  the  pubes 
available. 

3.  Measures  which  favor  expulsion  during  the  interval  between  the 
pains,  or  at  least  after  the  acme  has  subsided. 

In  ordinary  cases  Hohl's  method,  recommended  by  Olshausen,*  has 
rendered  me  excellent  service.  It  consists  in  applying  the  support 
not  to  the  perinasum  but  to  the  presenting  part.  To  this  end  the 
thumb  should  be  applied  anteriorly  to  the  occiput,  and  the  index  and 
middle  fingers  posteriorly  upon  that  portion  of  the  head  which  lies 
nearest  to  the  commissure.  The  unconstrained  position  of  the  hand 
enables  the  operator  to  exercise  effective  pressure  in  the  direction  of 
the  vagina,  while  the  posterior  fingers  favor  the  rotation  of  the  head 
under  the  pubic  arch.  The  patient  should  at  the  same  time  be  directed 
*  Olshausen,  loc.  cit.,  p.  366. 


212 


LABOR. 


not  to  hold  her  breath  during  the  pains,  except  when  they  are  weak 
and  powerless.  Where  the  impulse  to  bear  down  is  irresistible,  chloro- 
form should  be  given  to  annul  the  excessive  reflex  irritability.  Under 
the  most  skillful  management  laceration  is  liable  to  occur,  unless  the 
physician  is  able  to  control  the  action  of  the  auxiliary  expulsive  forces. 

So  soon  as  the  bi-parietal  diameter  passes  the  tense  border  of  the 
vulva  the  perineum  retracts  rapidly  over  the  face,  and  the  expulsion 
of  the  head  is  completed.  It  is  during  this  period  that  laceration  is 
most  apt  to  occur.  This  danger  is,  however,  greatly  lessened  if  the 
head  is  made  to  issue  through  the  orifice  after  the  pain  has  subsided, 
and  when  the  soft  parts  are  in  a  relaxed  and  dilatable  condition.  To 
accomplish  this,  in  many  instances  where  the  resistance  to  be  overcome 
is  slight,  it  is  sufficient  for  the  woman  to  hold  her  breath  during  an 
interval  between  the  pains,  and  voluntarily  call  into  play  all  the  mus- 
cles of  expiration.  In  the  larger  proportion  of  cases,  however,  these 
efforts  are  futile,  because  of  the  comparatively  feeble  motor  force 
brought  into  action. 

An  excellent  method  of  manual  delivery  we  owe  to  Eitgen,*  which 
consists  in  lifting  the  head  upward  and  forward  through  the  vulva, 
between  the  pains,  by  pressure  made  with  the  tips  of  the  fingers  upon 
the  perinifium  behind  the  anus  close  to  the  extremity  of  the  coccyx. 
Of  course,  the  metliod  is  only  available  after  the  head  has  descended 
sufficiently  for  the  pressure  to  be  exerted  upon  the  frontal  region. 

Rectal  expression  has  lately  found  warm  advocates  in  Olshausen  f 
and  Ahlfeld.J  The  manoeuvre  consists  in  passing  two  fingers  into  the 
rectum  toward  the  close  of  the  second  stage  of  labor,  and  hooking 
them  into  the  mouth  or  under  the  chin  of  the  child  through  the  thin 
recto-vaginal  septum.  By  pressing  the  face  forward  and  upward,  the 
normal  rotation  of  the  head  beneath  the  pubic  arch  can  be  effected, 
and  delivery  can  be  accomplished  between  the  pains  at  the  will  of  the 
operator. 

When  rupture  is  felt  to  be  imminent,  mock-modesty  should  be  dis- 
carded, and  the  parts  imperiled  should  be  unhesitatingly  exposed  to 
view.  If,  owing  to  its  excessive  elasticity,  the  occiput,  in  place  of 
being  directed  forward  to  the  vulva  by  the  perineum,  distends  the 
latter  so  that  central  perforation  threatens,  the  hand  should  be  applied 
in  such  a  way  as  to  give  direct  support  to  the  stretched  tissues  and  to 
guide  the  head  upward  to  the  outlet.  If, .  on  the  other  hand,  the 
danger  arises  from  defective  elasticity,  the  physician,  standing  to  the 
right  of  the  patient,  with  his  face  toward  the  foot  of  the  bed,  should 

*  Olshausen,  Ueber  Daramverletzung  und  Daii^raschutz,  Volkmann's  Samm- 
lung.,  No.  41,  p.  369. 

f  See  Ahlfeld,  Das  Dammschutz  Verfahren  nach  Ritgen,  Arch.  f.  Gynaek.,  vi, 
p.  279. 

X  Loc.  cit. 


CONDUCT   OF   NORMAL   LABOR.  213 

pass  the  left  hand  between  lier  thiglis  and  press  the  head  upward  and 
inward,  during  each  pain,  Avith  the  thumb  and  two  fingers,  as  previ- 
ously described.  At  the  same  time,  the  movement  of  extension,  should 
it  threaten  danger  to  the  parts,  should  be  hindered  by  pressing  back- 
ward upon  the  frontal  region,  through  the  perineum,  with  the  disen- 
gaged hand. 

Dr.  Goodell*  recommends  hooking  two  fingers  into  the  anus  and 
drawing  the  perina?um  forward  during  a  pain,  to  remove  the  strain 
from  the  thinned  border  of  the  vulva,  and  to  promote  the  elasticity  of 
the  tissues. 

Merkerttschiantz  advocates  the  emplojTnent  of  bilateral  pressure  upon  the 
periuffum  during  the  pains  to  diminish  the  tension  in  the  median  line  where 
rupture  usually  occurs.  To  accomplish  this  the  patient  lies  upon  her  back 
with  her  knees  moderately  separated.  The  physician  sits  to  the  right  of  the 
patient.  The  right  hand  is  then  placed  beneath  the  right  thigh,  with  the 
thumb  and  the  fingers  respectively  applied  to  points  on  the  right  and  left  of  the 
perinaeum.  The  points  selected  should  correspond  as  nearly  as  possible  to  the 
region  where  the  strain  is  the  greatest.  During  a  pain  the  thumb  and  fingers 
should  be  employed  to  press  the  perineal  tissues  from  the  sides  toward  the  cen- 
ter. When  the  presenting  part  begins  to  distend  the  vulva,  the  left  hand 
should  be  placed  with  the  ulnar  border  over  the  mons  veneris,  and  with  the 
thumb  and  fingers  resi^ectively  applied  to  the  right  and  left  labia.  As  the 
frfenulum  is  put  upon  the  stretch,  the  middle  finger  and  the  thumb  should  guard 
by  lateral  pressure  a  point  in  the  perinseum  about  half  an  inch  from  the  anterior 
border.  This  point  should  likewise  be  sustained  at  the  same  time  from  below 
by  the  thumb  and  fingers  of  the  right  hand.  Merkerttschiantz  f  reports  over 
110  cases  treated  by  this  method  without  a  single  perineal  laceration.  More 
recently  a  plan  which  is  the  same  in  principle  has  been  recommended  by  Dr. 
T.  J.  McGillicuddy,  of  this  city.^ 

Fasbender*  places  the  patient  upon  the  left  side;  then,  standing 
behind  her,  he  seizes  the  head  between  the  index  and  middle  fingers  of 
the  right  hand,  applied  to  the  occiput,  and  the  thumb  thrust  as  far 
into  the  rectum  as  possible.  By  this  manoeuvre  the  head  is  held  under 
complete  control,  the  rectal  wall  harrlly  affecting  the  grip  in  any  ap- 
preciable manner.  During  a  pain  the  progression  and  extension  of 
the  head  are  readily  prevented.  During  the  interval  between  the 
pains,  by  pressure  with  the  thumb  through  the  rectum  and  the  poste- 
rior portion  of  the  perinaeum,  the  head  can  be  pressed  forward  and  out- 
ward at  the  will  of  the  operator. 

Between  pains,  I  have  been  in  the  habit,  in  cases  of  rigidity,  of 
alternately  drawing  the  chin  downward  through  the  rectum  until  the 
head  distends  the  perinaeum,  and  then  allowing  it  to  recede.     It  is  as- 

*  Goodell,  Am.  Jour,  of  the  Med.  Sci.,  January,  1871. 

f  Merkerttschiantz,  Arch.  f.  Gynaek.,  vol.  xxvl,  p.  327,  1885. 
X  Vide  Am.  Jour.  Obst.,  Dec.,  1889,  p.  1341. 

*  Fasbender,  Ztschr.  f.  Geburtsh.  und  Gynaek.,  Bd.  ii,  H.  1,  p.  58. 


214: 


LABOR. 


tonisliing  how  often  apparently  the  most  obstinate  resistance  can  be 
oyercome  by  the  simple  repetition  of  this  to-and-fro  movement,  the 
parts  rapidly  becoming  soft  and  distensible.  Of  course  it  should  be 
discontinued  the  moment  contraction  begins,  and  care  should  be  taken 
to  effect  delivery  after  uterine  action  has  subsided. 

"With  judicious  management  the  number  of  unavoidable  lacerations 
can  be  restricted  to  a  small  proportion  of  cases.  Still,  there  are  indi- 
vidual peculiarities  which  Avill  now  and  then  render  abortive  the  best 
prophylactic  measures.  In  this. category  I  have  already  alluded  to  a 
primitive  lack  of  development  of  the  maternal  parts,  to  unusual  size 
of  the  child's  head,  and  to  the  excessive  rigidity  of  the  perineum  in 
primiparffi,  especially  after  the  thirtieth  year.  -In  addition,  should  be 
mentioned  cases  where  the  pubic  arch  is  diminished  by  the  approxi- 
mation of  the  pubic  rami,  or  where  the  tissues  have  been  rendered 
friable  from  chronic  oedema,  from  a  varicose  condition  of  the  veins, 
from  condylomata,  from  syphilitic  sores,  or  from  inflammatory  infil- 
tration consequent  ui)on  undue  jjrolougation  of  the  second  stage  of 
labor.  Lacerations  are  more  frequent  in  occipito-posterior  positions, 
and  in  the  delivery  of  the  after-coming  head,  where  hasty  extraction 
is  demanded  in  tlie  interest  of  the  child. 

When,  in  the  judgment  of  the  physician,  rupture  of  the  perina^um 
seems  inevitable,  he  is  justified  in  making  lateral  incisions  through  the 
vulva  to  relieve  the  strain  upon  the  recto-vaginal  septum.  To  this 
operation  tlie  term  episiotomy  is  applied.  By  it  not  only  is  the  danger 
of  deep  laceration  through  the  sphincter  ani  prevented,  but,  owing  to 
their  eligible  position,  the  wounds  themselves  are  capable  of  closing  spon- 
taneously ;  Avhereas,  when  laceration  follows  the  raphe,  the  retraction  of 
the  transversi  perinaii  muscles  causes  a  gaping  to  take  place  which  inter- 
feres with  immediate  union.  As,  however,  every  wounded  surface  is  a 
source  of  danger  in  childbed,  episiotomy  should  never  be  performed 
so  long  as  hope  exists  of  otherwise  preserving  the  perinaeum.  It  is 
essentially  the  operation  of  young  practitioners,  the  occasions  for  its 
employment  diminishing  in  frequency  with  increasing  experience. 
The  chief  resistance  encountered  by  the  head  is  not  at  the  thin  border 
of  the  vulva,  but  is  furnished  by  a  narrow  ring  situated  half  an  inch 
above,  and  composed  of  the  constrictor  cunni,  the  transversi  perina^i, 
and  sometimes  of  the  levator  ani  muscles.  Incisions  should  be  made 
during  a  pain,  Avhen  the  ring  becomes  tense  and  rigid,  and  is  easily 
recognized  with  the  finger.  As  it  is  not  desirable  that  the  head  should 
be  driven  suddenly  through  the  vulva  during  the  act  of  operating,  the 
time  selected  for  performing  episiotomy  should  be  at  the  commence- 
ment or  close  of  a  contraction.  The  division  of  the  rigid  fibers  may 
be  accomplished  by  means  of  a  blunt-pointed  bistoury,  or  a  pair  of 
angular  scissors.  So  far  as  practicable,  the  incisions  should  be  con- 
fined to  the  vagina,  and  should  not  exceed  three  quarters  of  an  inch 


CONDUCT   OF   NORMAL   LABOR.  215 

in  length.  In  cases  where  the  head  is  on  the  eve  of  expulsion,  the 
bistoury  may  be  introduced  flat  between  it  and  the  vagina,  half  an  inch 
anterior  to  the  commissure,  and  the  section  made  from  within  outward. 
Care,  however,  should  be  taken  at  the  same  time  to  avoid  severino-  the 
external  skin  by  drawing  it  us  far  back  as  possible.*  In  central  per- 
foration it  is  best  to  divide  the  band  left  attached  to  the  vulva,  as  its 
preservation  is  of  no  advantage. 

The  Delivery  of  the  Shoulders.— After  the  expulsion  of  the  head, 
mucus  should  be  wiped  from  the  mouth  and  nose,  and  cleared  from 
the  throat  with  the  finger  should  laryngeal  rales  indicate  an  embar- 
rassment of  the  respiration.  If  the  cord  is  found  coiled  around  the 
neck,  it  should  be  loosened  by  drawing  upon  the  placental  end  until 
the  shoulders  can  pass  readily  tlirough  the  loop.  Should  this  be  found 
impossible,  either  because  the  cord  is  unusually  short,  or  because  it  is 
wound  several  times  around  the  body,  a  ligature  should  be  applied, 
the  cord  should  be  cut  between  the  ligature  and  the  placenta,  and  de- 
livery should  be  hastened  by  manual  efforts,  f 

In  the  majority  of  cases  the  shoulders  are  expelled  spontaneously. 
Still,  it  is  a  good  plan  to  expedite  the  descent  by  pressure  made  with 
the  left  hand  at  the  fundus  of  the  uterus.  Care  must  be  taken  lest 
the  lower  shoulder  convert  a  slight  tear  in  the  perinjeum  into  an  ex- 
tensive laceration.  The  right  hand  should  therefore  be  applied  to  the 
perineum  in  such  a  way  as  to  lift  the  shoulder  upward,  and  at  the  same 
time  furnish  a  bridge  over  which  it  can  glide  in  its  movement  forward. 
Sometimes  after  the  j^assage  of  the  head  a  deep  vaginal  laceration  co- 
exists with  an  intact  condition  of  the  external  parts.  The  shoulder 
then  tears  through  the  skin,  and  a  complete  rupture  ensues.  Olshau- 
sen  recommends,  in  cases  where  rupture  is  imminent,  to  turn  the 
shoulders  so  that  they  clear  the  vulva  in  an  oblique  or  transverse 
diameter. 

If,  after  birth  of  the  head,  the  child  does  not  breath,  and  asphyxia 
threatens,  the  j^hysician  should  rub  the  uterus  with  the  hand  through 
the  abdominal  wall,  to  excite  a  pain,  during  which  he  should  urge  the 
patient  to  press  down,  and  thus  aid  expulsion.  The  most  common 
hindrance  to  delivery  consists  in  an  arrest  of  the  upper  shoulder  be- 
neath the  pubes.  Usually  its  release  is  readily  effected  by  seizing  the 
sides  of  the  head  with  the  two  hands  and  drawing  directly  downward. 
It  is  rarely  necessary  to  raise  the  head  subsequently,  or  to  hook  the 
finger  into  the  armpit  to  extract  the  posterior  shoulder. 

Tying  the  Cord.— When  the  cord  is  torn  across,  as  sometimes  hap- 
pens in  street-births,  no  hemorrhage  takes  place  from  the  lacerated 

*  Olshausen,  loc.  cit.,  pp.  372,  373. 

t  Tarnier  recommends  dividing^  the  cord  and  then  compressing  the  proximal 
end  between  the  thumb  and  the  ind'ex^finger.  The  proximal  end  is  uistinguisheC 
by  the  spouting  of  the  two  umbilical  arteries. 


216 


LABOR. 


vessels.  Of  course,  this  occurrence  deprives  the  physician  of  the 
power  of  choosing  the  point  at  which  the  division  sliall  be  made.  As 
it  is  desirable,  for  the  sake  of  convenience,  to  sever  the  cord  about  two 
inches  from  the  navel,  it  is  the  custom  in  all  civilized  countries  to  cut 
it  with  scissors,  and  to  prevent  hemorrhage  by  the  application  of  a 
ligature.  Almost  any  material  may  be  employed  for  the  latter  purpose, 
though  nothing  is  so  handy  as  the  narrow  flat  bobbin  which  most 
nurses  keep  in  readiness.  Dr.  Craig,  of  Jersey  City,  recommends  the 
use  of  an  clastic  ligature  as  a  security  against  haemorrhage.  The 
ligature  should  be  applied  tightly,  and  the  cut  surface  should  subse- 
quently be  examined  once  or  twice  by  the  physician  before  leaving,  to 
make  sure  that  the  arteries  are  sufficiently  compressed  to  prevent  oozing 
from  taking  place.  The  cord  should  be  held  in  the  hollow  of  the  hand 
at  the  time  of  its  division,  to  avoid  the  possibility  of  including  ac- 
cidentally any  portion  of  the  child  between  the  blades  of  the  scissors. 
Commonly  two  ligatures  are  applied,  and  the  cord  is  severed  between 
them,  though  the  question  of  one  or  two  ligatures  is,  excei^t  in  twin 
pregnancies,  of  trifling  importance. 

In  practice  it  is  very  desirable  that  the  physician  should  understand 
the  physiological  difference  between  the  effects  of  the  early  and  those 
of  the  late  application  of  the  ligature.  The  custom  as  regards  this 
point  has  been  by  no  means  uniform.  The  ancients  deferred  the  liga- 
ture until  after  the  expulsion  of  the  placenta.  Mauriceau,  Clement, 
and  Deventer  followed  the  same  plan,  but  employed  artificial  expe- 
dients to  complete  the  third  stage  of  labor  rapidly.*  The  common 
practice  at  the  present  day  is  to  tie  the  cord  immediately  after  the 
birth  of  the  child.  Still,  there  have  not  been  wanting  in  recent 
times  warning  voices  against  precipitate  action.  Naegele  advised  wait- 
ing until  the  pulsation  of  the  cord  had  ceased  ;  Braun  f  first  describes 
the  changes  from  the  fetal  to  the  post-natal  circulation,  and  then  says : 
"  This  stupendous  process  should  be  taken  into  consideration  in  the 
treatment  of  every  case  of  labor,  and  because  of  it  the  cord  should 
never  be  severed  or  tied  so  long  as  pronounced  pulsations  can  be  felt 
near  the  navel."     Stoltz  I  noticed  that  "  after  the  child  has  respired 

*  BuDiN,  A.  quel  moment  doit-on  operer  la  ligature  du  cordon  ombilical  ?  Publi- 
cations (lu  Progres  Medical,  1876. 

t  Braun,  Lehrbuch  der  Geburtshiilfe,  p.  192. 

X  Stoltz,  art.  Accouchement  naturel,  Nouveau  Dictionnaire,  p.  283.  So.  too, 
WurrE  wrote,  in  1773 :  "  The  common  method  of  tying  and  cutting  the  navel- 
string  the  instant  the  child  is  born  is  likewise  one  of  those  errors  in  practice  that 
has  nothing  to  plead  in  its  favor  but  custom.  Can  it  be  supposed  that  this  im- 
portant event,  this  great  change  which  takes  place  in  the  lungs,  the  heart,  and  the 
liver,  from  the  state  of  a  foetus  kept  alive  by  the  umbilical  cord  to  that  state  when 
life  can  not  be  carried  on  without  respiration,  whereby  the  lungs  must  be  fully  ex- 
panded with  air.  and  the  whole  mass  of  bloofl,  instead  of  one  fourth  part,  be  cir- 
culated through  them,  the  ductus  venosus,  foramen  ovale,  ductus  arteriosus,  and  the 


I 


CONDUCT  OF  NORMAL  LABOR.  9^^ 

well  division  of  the  cord  is  followed  by  an  insignificant  loss  of  blood, 
while  after  immediate  section  blood  escapes  in  abundance."  Winkler,* 
from  anatomical  observation  alone,  recommended  not  to  tie  the  cord 
until  the  expulsion  of  the  placenta,  or  at  least  until  the  cord  had  be- 
come pale  and  had  ceased  to  pulsate,  giving  as  his  reason  that  by 
delay  a  certain  quantity  of  blood  would  pass  from  the  placenta  to  the 
child,  and  tliat  every  plus  is  a  gain  to  the  child,  which  would  increase 
its  powers  of  resistance.  He  finally  expressed  it  as  almost  his  belief 
that  the  practice  recommended  would  tend  to  diminish  the  familiar 
loss  of  weight  in  the  new-born  during  the  first  days  of  existence. 

In  1875,  Budin,  at  that  time  interne  at  the  Maternite  of  Paris, 
undertook  the  following  experiments  at  the  suggestion  of  Professor 
Tarnier :  In  one  series,  the  cord  was  tied  immediately  after  tlie  birth  of 
the  child,  and  the  blood  which  escaped  from  the  placental  extremity 
was  measured ;  in  the  other,  tlie  quantity  of  blood  was  determined  ia 
cases  where  the  cord  was  not  tied  until  several  minutes  after  delivery. 
By  a  comparison  of  the  results  thus  obtained,  he  found  that  the  aver- 
age amount  of  placental  blood  was  three  ounces  greater  in  the  first 
than  in  the  second  series  of  experiments.!  Welcker  estimated  the 
entire  quantity  of  the  blood  in  the  infant  at  one  nineteenth  the  weight 
of  the  body,  which  would  amount,  in  a  child  of  seven  pounds,  to  six 
ounces.  To  tie  the  cord  immediately  after  birth  would  therefore  be 
equivalent  to  robbing  the  child  of  three  ounces  of  blood  which  would 
otherwise  pass  into  its  circulation.  This  startling  result  has  in  the 
main  been  abundantly  confirmed  by  subsequent  observers.  Two  years 
later  (18TT),  Schiicking,  extending  Budin's  experiments  by  weighing 
the  cliild  at  birth  and  then  observing  the  changes  that  took  place  up 
to  the  time  of  the  cessation  of  the  placental  circulation,  found  that  the 
child  gained  from  one  to  three  ounces  in  Aveight  by  delay.  It  is  cer- 
tain that  these  amounts  do  not  represent  the  entire  increase,  as  a  portion 
necessarily  escapes  observation  in  the  interval  that  must  elapse  before 
the  weight  can  be  ascertained. 

There  is  a  difference  of  opinion  as  to  the  mechanism  by  which  the 

umbilical  arteries  and  veins  must  all  be  closed,  and  the  mode  of  circulation  in  the 
principal  vessels  entirely  altered — is  it  possible  that  this  wonderful  alteration  in 
the  human  machine  should  be  properly  brought  about  in  one  instant  of  time,  and 
at  the  will  of  a  bystander  i  Let  us  but  leave  the  afifair  to  Nature  and  watch  her 
operations,  and  it  will  soon  appear  that  she  stands  not  in  need  of  our  feeble  as- 
sistance, but  will  do  the  work  herself  at  a  proper  time  and  in  a  better  manner.  In 
a  few  minutes  the  lungs  will  be  gradually  expanded,  and  the  great  alterations  in 
the  heart  and  blood-vessels  will  take  place.  As  soon  as  this  is  perfectly  done  the 
circulation  in  the  navel-string  will  cease  of  itself,  and  then  if  it  be  cut  no  hjpraoi- 
rhage  will  ensue  from  either  end.  .  .  ."  A  Treatise  on  the  ISIanagement  of  Pregnant 
and  Lying-in  Women,  by  Charles  White,  London,  1873,  p.  107. 

*  Winkler,  Arch.  f.  Gynaek.,  vol.  iv.  p.  250  (1872). 

f  Budin,  loc.  cit. 


218 


LABOR. 


transfer  of  the  blood  from  the  placenta  to  the  child  takes  place.  Ac- 
cording to  Budin,  the  principal  factor  in  the  accomplishment  of  the 
result  is  thoracic  aspiration.  With  the  first  breath,  the  afflux  of  blood 
to  the  lungs  develops  a  "  negative  pressure  "  in  the  vessels  of  the  larger 
circulation,  so  that  a  suction  force  is  exerted  upon  the  placental  blood, 
which  continues  until  the  equilibrium  is  restored.  To  tie  the  cord 
prematurely,  therefore,  is  to  cut  off  from  the  child  a  supply  of  blood 
for  which  the  establishment  of  the  pulmonary  circulation  had  created 
a  physiological  need. 

Schiickiug,*  on  the  contrary,  maintains  that,  after  the  first  inspira- 
tion, thoracic  expansion  ceases  to  operate  as  an  active  force,  and  that 
the  main  agent  which  drives  the  blood  from  the  placenta  through  the 
umbilical  vein  is  the  compression  exerted  by  the  retraction,  and,  at 
intervals,  by  the  contractions  of  the  uterus. 

The  difference  in  the  theoretical  standpoint  of  these  two  observers 
is  of  practical  importance,  for,  if  the  movement  of  blood  to  the  child 
results  from  thoracic  aspiration,  the  quantity  which  enters  its  circula- 
tion will  not  exceed  its  requirements ;  while,  if  the  movement  is  due 
to  uterine  compression,  the  question  arises  as  to  whether  the  forcible 
transfusion  thus  accomplished  is  compatible  with  the  child's  safety 
and  welfare.  The  ultimate  decision  will  depend  partly  upon  experi- 
mental and  partly  upon  clinical  observations.  Provisionally,  the  case 
stands  as  follows :  The  manometric  observations  of  Ribemont  f  show 
that  the  pressure  in  the  umbilical  arteries  is  uniformly  greater  than 
that  in  the  umbilical  vein ;  during  a  series  of  deep  inspirations  and 
expirations  tlie  blood  in  the  umbilical  vein  is  subject  to  marked  oscil- 
lations; after  the  pulsations  of  the  cord  have  ceased,  the  uterine  con- 
tractions alone  are  insufficient  to  propel  the  placental  blood  through 
the  umbilical  vein  to  the  infant.  Again,  Budin  (discussion  upon 
Ribemont's.  paper),  in  a  breech-delivery,  compressed  the  cord  at  the 
vulva  as  far  as  possible  from  the  navel ;  at  birth,  the  vein  was  dis- 
tended with  blood,  but  with  the  first  inspiration  it  was  instantly 
emptied.  Thoracic  aspiration  does,  therefore,  exist  as  an  operative 
force.  On  the  other  hand,  Schiicking  found  that  when  the  placenta 
was  rapidly  expelled  by  Crede's  method,  so  as  to  remove  it  from  the 
influence  of  uterine  retraction,  the  pressure  in  the  vein  was  slightly 
lessened,  and  the  total  amount  of  blood  transferred  to  the  infant  was 
greatly  restricted. 

According  to  the  clinical  observations  of  Budin,  Ribemont,  and 
Schiicking,  infants  which  have  had  the  benefit  of  late  ligation  of  the 
cord  are  red,  vigorous,  and  active,  whereas  those  in  which  the  cord 

*  ScHucKiNG,  Zur  Physiologie  der  Nachgeburtsperiode,  Berl.  klin.  Woch.,  Nos. 
1  and  2,  1877. 

f  Ribemont,  Recherches  sur  la  tension  du  sang  dans  les  vaisseaux  du  foelus  et 
du  nouveau-ne,  Arch,  de  Toeol.,  October,  1879. 


OUNDUOT  OF   NORMAL  LABO£.  211) 

is  tied  early  are  apt  to  be  pale  and  apathetic.  Hofmeier,*  Ribemont, 
Badin,  and  Zweifel  f  have  shown  that  the  loss  of  weight  wliich  occurs 
in  the  first  few  days  following  confinement  is  less  in  amount  and  of 
shorter  duration  when  the  cord  is  not  tied  until  after  the  pulsations 
have  ceased. 

There  appear  to  be  no  harmful  results  to  the  child  growino-  out  of 
the  practice  of  late  ligation.  Porak,  indeed,  reports  two  cases  of  dai-k 
vomiting,  two  of  mel^ua,  and  two  with  sanguineous  discharges  from 
the  vagina,  which  he  is  convinced  were  the  result  of  the  practice;  but 
the  extensive  trial  to  which  it  has  since  been  subjected  in  the  principal 
lying-in  institutions  of  the  Continent  have  sufficiently  demonstrated 
that  it  is  exempt  from  danger. 

In  late  ligation,  the  amount  of  blood  retained  in  the  placenta  and 
the  increase  in  the  weight  of  the  child  differ  materially  in  different 
eases  I — a  difference  which  seems  to  indicate  that,  so  long  as  the  placen- 
tal circulation  is  left  undisturbed,  the  amount  of  blood  passing  to  the 
child  will  be  measured  by  its  needs.  In  a  case  of  Illing's,*  on  the 
other  hand,  after  the  placenta  had  been  expressed  from  the  uterus,  its 
contents  and  that  of  the  cord  were  forcibly  squeezed  into  the  circula- 
tion of  the  child,  and  death  followed  from  overdistention  of  the  heart. 
Porak  and  Georg  Violet  |  claim  that  there  is  a  special  predisposition 
to  icterus  in  children  when  the  cord  is  tied  after  the  placental  circula- 
tion has  ceased.  Violet  attributes  the  discoloration  not  to  bile-pig- 
ment but  to  a  rapid  disintegration  of  the  excess  of  blood-corpuscles. 
Helot,  he  says,  found  on  the  first  day  after  the  birth  a  difference  of 
nine  hundred  thousand  corpuscles  to  the  cubic  millimetre  between 
cases  of  late  and  those  of  early  ligation,  while  on  the  ninth  day  the 
difference  fell  to  three  hundred  thousand.  Others  have  failed  to 
notice  any  characteristic  icteric  discoloration  peculiar  to  late  ligation. 
Neither  Porak  nor  Violet  attaches  any  pathological  significance  to  the 
symptom. 

The  outcome  of  the  foregoing  observations  may  fairly  be  stated  as 
follows  : 

1.  The  cord  should  not  be  tied  until  the  child  has  breathed  vigor- 
ously a  few  times.  When  there  is  no  occasion  for  haste  arising  out  of 
the  condition  of  the  mother,  it  is  safer  to  wait  until  the  pulsations  of 
the  cord  have  ceased  altogether. 

*  Der  Zeitpunkt  der  Abnabelung,  etc.,  Ztschr.  f.  Geburtsh.  u.  Gyiiaek.,  iv,  1, 
p.  114. 

f  Zweifel,  Centralbl.  f.  Gyiiaek.,  No.  1. 

i  See  Wiener,  Ueber  den  Einfluss  der  Abnabelungszeit  auf  den  Blutgehalt  der 
Placenta,  Arch.  f.  Gynaek.,  xiv,  1,  p.  34;  also,  Meyer,  Centralbl.  f.  Gynaek.,  1878, 
No.  10. 

*  Inaug.  Diss.,  Kiel,  1877. 

II  Georg  Violet,  Ueber  die  Gelbsucht  der  Neugeborenen  und  die  Zoit  der 
Abnabelung,  Virchow's  Archiv,  Ixxx,  3,  p.  353. 


220 


LABOR. 


2.  Late  ligation  is  not  dangerous  to  the  child.  From  the  excess  of 
blood  contained  in  the  fetal  portion  of  the  placenta,  the  child  receives 
into  its  system  only  the  amount  requisite  to  supply  the  needs  created 
by  the  opening  up  of  the  pulmonary  circulation. 

3.  Until  further  observations  have  been  made,  the  practice  of 
employing  uterine  expression  previous  to  tying  the  cord  is  question- 
able. 

4.  In  children  born  pale  and  anaemic,  suffering  at  birth  from  syn- 
cope, late  ligation  furnishes  an  invaluable  means  of  restoring  the  equi- 
librium of  the  fetal  circulation. 


Management  of  the  Third  or  Placextal  Stage  of  Labor. 

The  duties  of  the  physician  in  the  third  stage  are  to  guard  against 
hfemorrhage,  to  promote  uterine  contractions,  and  to  farther  the  ex- 
pulsion of  the  placenta.  These  objects  are  best  fulfilled  by  manipula- 
tions through  the  abdominal  walls.  Tractions  upon  the  cord  should 
not  be  resorted  to  before  the  placenta  has  accomplished  its  descent 
into  the  vagina.  The  method  of  expressing  the  placenta  by  seizing 
the  uterus  through  the  abdominal  coverings  is  associated  indissolubly 
with  the  name  of  Crede,  for,  though  the  value  of  friction,  of  knead- 
ing, and  compression,  was  appreciated,  as  their  writings  show,  by  Mau- 
riceau,  Robert  Wallace  Johnson,  Joseph  Clarke,  Busch,  Mayer,  and 

others,*  it  was  Crede  who,  by  in- 
dependent study,  worked  out  the 
practical  details  of  the  manoeu- 
vre, and  by  his  advocacy  gained 
for  the  principle  of  placental  ex- 
pression its  present  wide-spread 
acceptance. 

Crede's  method  consists  es- 
sentially in  applying  at  first  light 
and  afterward  stronger  friction 
to  the  fundus  of  the  uterus  until 
an  energetic  contraction  is  ob- 
tained ;  at  its  height  the  uterus 
is  grasped  so  that  the  fundus 
rests  in  the  palm  of  the  hand, 
compressed  between  the  thumb 
and  fingers.  The  exercise  of 
circular  compression  forces  the 
placenta  from  the  uterus,  or  in  case  of  failure  the  process  may  be 
repeated  until  the  object  is  accomplished.     Crede   lays  great  stress 

*  For  historical  references,  vide  Riol,  Delivrance  par  expression,  G.  Masson, 
1880 ;  MuNDE,  Obstetric  Palpation,  p.  103. 


Fig.  122.— Expression  of  the  placenta.    (Cred6.) 


CONDUCT  OF  NORMAL  LABOR.  221 

upon  the  avoidance  of  violence  in  the  practice  of  his  method.  It  is 
true  that  the  expulsion  of  the  placenta  will,  as  a  rule,  occur  spontane- 
ously. The  unaided  uterus  is,  however,  liable  to  relax  and  become  the 
source  of  hajniorrhage ;  or,  where  the  delivery  does  not  take  place 
speedily,  it  may,  on  the  other  hand,  close  down  so  as  to  imprison  the 
placenta  within  its  cavity.  The  great  merit  of  Crede's  method  is 
that  by  maintaining  retraction  it  prevents  hasmorrhage,  and  by  pro- 
moting speedy  expulsion  it  guards  against  the  dangers  of  retention. 
When  systematically  practiced,  the  bugbear  known  as  adherent  pla- 
centa is  the  rarest  of  accidents.  The  method  is  not  difficult,  and  is 
devoid  of  danger.  To  be  successful,  however,  expression  should  ])e 
employed  only  during  the  acme  of  a  contraction,  and  the  propulsive 
force  should  be  directed  from  the  fundus  downward  in  the  axis  of  the 
uterus. 

Crede  in  his  earlier  papers  advocated  the  expression  of  the  placenta 
as  soon  after  the  birth  of  the  child  as  possible.  It  appears,  however, 
from  the  observations  of  Schroeder  and  others,  that  in  most  cases  the 
placenta  spontaneously  leaves  the  uterine  cavity,  either  in  whole  or  in 
part,  within  the  first  fifteen  to  twenty  minutes  after  the  birth  of  the 
cliild,  and  that  the  delay  observable  in  so  many  cases  left  to  the  un- 
aided elforts  of  Nature  occurs  usually  after  the  placenta  has  sunk  into 
the  lower  uterine  segment.  For  this  reason  it  is  a  good  rule,  accepted 
of  late  by  Crede,  not  to  resort  to  external  manipulations  until  at  least 
fifteen  minutes  have  exjjired. 

The  evidence  of  the  expulsion  of  the  placenta  is  furnished  to  the 
operator  by  his  feeling  the  anterior  and  posterior  walls  in  contact  with 
one  another.  By  thei^  pressing  the  uterus  downward  in  the  axis  of  the 
brim  it  is  usually  possible  to  drive  the  placenta  through  the  vagina 
and  out  of  the  valva.  There  is  no  objection,  however,  at  this  stage,  in 
case  of  delay,  to  expedite  delivery  by  drawing  upon  the  cord  downward 
and  backward.  When  the  placenta  passes  the  vulva  the  uterus  is  often 
firmly  contracted,  and  a  considerable  portion  of  the  membranes  are 
still  within  the  uterine  cavity.  Hasty  traction  is  then  apt  to  tear  off 
the  retained  part  of  the  membranes.  It  is  well,  therefore,  at  this  point 
to  support  the  placenta  until  relaxation  of  the  uterus  has  taken  place, 
when  the  complete  separation  of  the  membranes  is  effected  without 
endangering  their  integrity. 

There  has  been  considerable  discussion  of  late  as  to  the  true  physi- 
ology of  placental  expulsion.  Thus  it  has  been  maintained  by  Schultze 
that  after  the  birth  of  the  child  the  diminution  of  the  placental  area 
during  a  uterine  contraction  is  followed  by  a  central  separation  of  the 
placenta  from  the  uterine  walls  and  by  a  bulging  of  the  separated 
portion  into  the  uterine  cavity.  The  detachment  takes  place  in  the 
decidual  layer  ;  the  mouths  of  uterine  vessels  are  consequently  opened 
up,  and  blood  is  aspirated  into  the  retro-placental  cavity.     As,  in  i)oint 


222 


LABOR. 


regular 


Fig. 


of  fact,  no  uterine  cavity  exists  during  a  contraction,  Colm  *  modified 
the  Schultze  theory  by  assuming  that  the  central  separation  takes 
place  in  fact  as  a  consequence  of  uterine  contraction,  but  that  the 

hematoma  follows  upon  the  occurrence  of 
uterine  relaxation.  The  further  separa- 
tion of  the  placenta  from  the  center  to- 
ward the  periphery  is  either  the  result  of 
the  increase  in  the  amount  of  the  effused 
blood,  or  is  effected  during  a  contraction 
by  the  peripheral  pressure  exerted  by  the 
blood  previously  aspirated  behind  the  pla- 
centa. According  to  Schultze,  therefore, 
the  placenta  normally  descends  by  its  fetal 
surface  into  the  vagina,  and  a  certain 
amount  of  hnemorrhage  is  the 
concomitant  of  placental  expulsion 

Dohrn,t  accepting  the  views  of  Schultze, 
objects  to  Cred6,  that  by  his  metliod  "  a  proc- 
ess which  should  develop  naturally  is  disturbed 
by  a  comparativelj'  brusque  manipulation."  As 
a  result  of  hasty  placental  expression,  he  men- 
tioned as  especially  to  be  deprecated  the  tend- 
ency to  retention  of  the  membranes.  Later, 
Ahlfeld  I  urged  against  the  Cred6  method  that 
it  increased  the  cases  of  dangerous  haemorrhage,  that  it  favored  retention  of 
the  membranes,  and  that,  as  a  consequence  of  the  latter  accident,  it  created  a 
disposition  to  puerperal  fever.  The  evils  depicted  by  Dohrn,  and  especially  by 
Ahlfeld,  of  the  results  of  manual  expression  of  the  placenta,  were  so  entirely 
opposed  to  my  own  experience,  that  during  the  past  ten  years  I  have  continued 
to  follow,  with  slight  modifications,  the  counsels  of  CYede,  and  remain  uncon- 
vinced that  they  do  not  furnish  the  best  practical  solution  of  the  safe  manage- 
ment of  the  stage  of  labor.  When  skillfully  performed,  I  know  of  no  other 
obstetrical  manoeuvre  to  which  the  terms  cito  tuto,  etjucunde  can  be  so  properly 
applied. 

As  to  the  alleged  dangers  of  the  method,  my  experience  corresponds  to  that 
of  Roemer,*  of  Zinstag,||  of  Fehling,^  and  of  Cred6,0  whose  comparative  sta- 

*  CoHX,  Zur  Physiologie  und  Diatetik  der  Naehgeburtsperiode,  Ztschr.  f.  Ge- 
burtshiilfe  und  Gynaek.,  vol.  xii,  p.  .381. 

■f-  DoHRN,  Deutsche  med.  Wochenschr.,  1880,  No.  41. 

X  Ahlfeld,  Berichte  und  Arbeiten  aus  Giessen,  1881  and  1882. 

*  RoEMEB,  Klinische  Beobachtungen  ueber  der  Nachgeburtszeit,  Arch.  f.  Gy- 
naek., vol.  xxviii,  p.  283. 

II  ZiNSTAG,  Beitrage  zum  Mechanismus  der  physiologischen  Losung  der  Placenta, 
Arch.  f.  Gynaek.,  vol.  xliii,  p.  255. 

^  Peeling,  Zur  Frage  der  Zweckmassigsten  Behandlung  der  Nachgeburtszeit, 
Centralblatt  fur  Gynaek.,  1880,  No.  25. 

0  Crede,  Die  Behandlung  der  Naehgeburt  bei  regelmassigen  Geburten,  Arch,  f. 
Gynaek.,  vol.  xxxii,  p.  96. 


12.3.— Descent  of  the  placenta 
according  to  Schultze. 


CONDUCT  OP  NORMAL  LABOR. 


223 


tistics  show  that  Credo's  method  does  not  increase  the  quantity  of  blood  lost 
either  in  the  third  stage  or  during  the  puerperium ;  that,  unless  resorted  to  at  too 
early  a  period,  it  does  not  conduce  to  retention  of  the  membranes;  and  that, 
even  if  this  accident  should  occur,  it  does  not,  with  rigid  antiseptic  conduct  of 
labor,  enhance  the  risks  of  puerperal  infection. 

In  opposition  to  Schultze,  Duucan  maiutaius  that  when  the  mech- 
anism of  placental  delivery  is  not  interfered  with  by  premature  trac- 
tions upon  the  cord,  the  placenta  descends  edgewise  through  the  cervix, 
and  its  expulsion  is  effected  with  the  loss  of 
but  a  trifling  amount  of  blood.  Of  course 
it  is  understood  that  traction  upon  the  cord 
is  of  common  occurrence  during  the  birth 
of  the  child,  and  that  in  consequence  the 
Schultze  method  of  descent  is  frequently 
enough  met  with.  But  Zinstag  furnishes  us 
observations  in  one  hundred  and  thirty  cases 
in  which  the  cord  was  divided  when  coiled 
around  the  neck  of  the  child  immediately 
after  the  birth  of  the  head,  and  in  other  cases 
during  the  passage  of  the  breech.  When 
this  precaution  was  taken  the  mechanism  of 
Schultze  occurred  in  nine  cases  only ;  that 
of  Duncan  *  with  the  placenta  folded  on  the 
fetal  surface  in  ninety-four  cases;  and  in 
twenty-seven  cases  with  the  edge  presenting 
but  with  the  placenta  folded  upon  the  uterine 
surface,  and  with  a  certain  amount  of  blood 
effused  from  the  uterine  sinuses  between 
the  folds  and  behind  the  membranes. 

As  a  matter  of  practical  importance,  it  is  well  to  remember  that 
when  extraction  is  attempted  previous  to  descent  by  pulling  upon  the 
cord,  the  central  portion  of  the  placenta  is  dragged  into  the  cervix, 
while  the  borders  are  inverted  in  such  a  way  as  to  form  a  cup-like 
cavity.  This  disturbance  of  the  normal  mechanism  not  only  increases 
the  difficulty  of  delivering  the  placenta,  but  causes  the  latter  to  exer- 
cise a  suction  force  which  increases  the  haemorrhage,  and  at  times  even 
is  capable  of  partially  inverting  the  lax  uterine  walls.  Now  and  then, 
where  the  occlusion  of  the  cervix  is  complete,  it  may  be  found  impos- 
sible to  effect  delivery  without  first  introducing  two  fingers  and  hook- 
ing down  the  margin  of  the  placenta,  so  as  to  allow  air  to  pass  above 
into  the  uterine  cavity. 

*  Matthews  Duncan,  Edinburgh  Med.  Jour.,  April,  1871. 


Fig.  124.— Showing  normal  de- 
scent of  placenta.    (Duncan.) 


224  LABOR. 

Care  of  the  Patient  after  Delivery. 

As  the  danger  of  haemorrhage  does  not  always  end  with  placental 
expulsion,  the  physician  should  be  ready  to  sacrifice,  even  in  simple 
cases,  at  least  a  half-hour  to  close  observation  ©f  the  subsequent  be- 
havior of  the  uterus.  The  weight  of  the  hand  laid  above  the  sym- 
physis pubis  is  usually  sufficient  to  maintain  a  safe  degree  of  retrac- 
tion. Should,  however,  the  uterus  become  lax,  and  lose  its  outline,  the 
physician  should  grasp  it  in  his  hand  and  knead  it  firmly  until  a  con- 
traction  is  excited.  In  this  way  he  not  only  guards  against  haemor- 
rhage, but,  by  preventing  the  formation  of  clots,  he  diminishes  in  mul- 
tiparae  the  severity  of  the  after-pains. 

Most  physicians  seek  additional  security  against  haemorrhage  by 
administering  ergot,  which,  as  is  well  known,  favors  tonic  retraction 
of  the  uterus.  To  this  there  is  no  objection,  provided  the  ergot  be 
given  subsequent  to  the  expulsion  of  the  placenta.  When  given,  as 
is  commonly  done,"  at  the  time  of  the  passage  of  the  child's  head,  it  is 
liable  to  produce  its  effect  prematurely,  and  thus  to  give  rise  to  hour- 
glass contraction.  The  rarity  of  the  accident  is  no  argument  in  favor 
of  the  popularity  of  the  practice  in  the  face  of  the  serious  complica- 
tion to  which  it  is  capable  of  giving  rise.  When  the  physician  judges 
it  is  safe  to  suspend  the  prophylactic  pressure  upon  the  uterus,  ho 
should  see  that  all  the  soiled  clothing  be  removed  from  beneath  his 
patient,  and  that  the  nurse  wash  the  genitalia  gently  but  thoroughly. 
Nothing  does  so  much  to  cause  speedy  disappearance  of  the  soreness  of 
the  external  parts  as  perfect  cleanliness.  In  hospitals,  a  vaginal  douche 
of  warm  carbolized  water  should  be  combined  with  external  ablutions. 
The  perinifium  should  then  be  carefully  examined,  and,  if  lacerations 
are  discovered,  the  physician  should  make  himself  acquainted  with 
their  extent  and  importance. 

Without  entering  into  a  discussion  at  this  place  of  the  methods 
of  repairing  perineal  tears,  it  is  proper  to  state  that,  both  as  a  means 
of  preventing  infection  and  of  promoting  speedy  convalescence,  it  is 
wise,  in  all  cases  where  the  laceration  extends  to  or  nearly  to  the 
sphincter  ani,  to  bring  the  torn  surfaces  together  by  means  of  sut- 
ures. The  technique  is  simple,  and  immediate  union  is  the  rule,  if 
the  same  care  is  employed  with  regard  to  cleanliness  that  is  usual  in 
gynaecological  practice.  Rarely,  failures  to  obtain  union  may  result 
from  syphilis,  or  from  lowered  vitality  of  the  tissues  due  to  extreme 
prolongation  of  the  second  stage  of  labor. 

The  application  of  the  binder  is  one  of  those  points  in  practice 
about  which  men  of  large  experience  entertain  a  difference  of  opinion. 
In  my  student  days  in  the  Ilopital  des  Cliniques  in  Paris  the  binder 
was  dispensed  with.  A  folded  sheet  was,  however,  laid  across  the 
abdomen,  it  having  been  found  that  a  certain  amount  of  pressure  was 


CONDUCT  OF  NORMAL  LABOR.  225 

necessary  for  the  comfort  of  tlie  patient.  This  plan  compelled  her  to 
lie  upon  her  back,  and  thus  had  the  disadvantage  of  restrictino- freedom 
of  movement.  Careful  observation  has  failed,  however,  to  show  me  a 
single  good  reason  why  the  binder  should  be  discarded.  When  properly 
applied,  it  adds  greatly  to  the  woman's  comfort,  and  enables  her  to  turn 
at  will  upon  her  side.  My  own  preference  is  for  a  piece  of  unbleached 
muslin  wide  enough  to  reach  below  the  hips. 

In  adjusting  the  binder,  the  physician  should  place  himself  to  the 
right  of  the  woman ;  he  should  seize  the  near  end  between  the  thumb 
and  two  fingers  of  the  left  hand,  while  with  the  right  hand  he  draws 
the  further  portion  smoothly  over  it.  The  two  ends  should  then  be 
held  with  the  left  hand,  and  the  pins,  which  should  preferably  be  of 
large  size,  should  be  inserted  with  the  right.  The  process  should  begin 
below,  and  be  followed  upward  at  intervals  of  about  two  inches.  These 
details  are  given  because  the  writer  remembers  his  own  embarrassment 
arising  from  his  inability  to  get  information  upon  this  trivial  subject  in 
the  early  days  of  his  practice.  Moreover,  as  many  women  are  somewhat 
tenacious  of  having  the  binder  first  applied  by  the  physician,  to  know 
how  to  do  it  with  address  is  not  an  indifferent  accomplishment.  Many 
place  a  compress  made  of  a  folded  towel  above  the  symphysis  pubis. 
This  addition  usually  serves  no  better  purpose  than  to  displace  the 
uterus  to  one  side.  The  toilet  of  the  patient  is  finally  completed  by 
laying  a  warm  folded  napkin  at  the  vulva  to  receive  the  lochial  dis- 
charge. 

An  aseptic  dressing  to  the  external  parts  is,  however,  warmly  to 
be  recommended  in  private  as  well  as  in  hospital  practice.  This  con- 
sists after  washing  the  genitals  thoroughly  with  a  bichloride  solution 
(1  to  3,000),  in  powdering  the  parts  with  iodoform,  and  then  applying 
iodoform  or  bichloride  gauze.  The  dressings  should  be  held  in  place 
by  an  oakum  pad.  A  little  attention  to  these  details  possesses  the 
immense  advantage  of  preventing  decomposition  of  the  lochia  and  of 
promoting  the  healing  of  external  wounds. 

Anesthetics  ix  Midwifery. 

The  value  of  anassthetics  in  certain  irregularities  of  the  labor- 
pains,  in  eclampsia,  and  in  most  midwifery  operations,  is  no  longer  a 
matter  of  discussion.  The  benefits  from  their  employment  in  such 
cases  are  palpable  and  beyond  dispute.  As  to  the  right,  however,  of  a 
woman  to  have  her  sufferings  assuaged  in  ordinary  normal  labor,  there 
is  by  no  means  unanimity  of  opinion.  To  be  sure,  the  old  objections 
raised  in  Sir  James  Simpson's  day,  that  labor-pain  is  a  salutary  mani- 
festation of  life-force,  that  anaesthesia  gives  rise  to  paralysis,  to  peri- 
tonitis, to  puerperal  mania,  to  haemorrhage,  to  pericardial  adhesions,  to 
indecencies  of  language  and  behavior,  and  that  it  contravenes  the  Word 
15 


226  LABOR. 

of  God,  are  now  known  to  be  unfounded  or  imaginary.  Still,  there  is 
no  doubt  that  the  vast  majority  of  medical  men  refrain  from  the  use 
of  anesthetics  in  ordinary  labor,  either  from  vain  apprehensions  or 
because  some  incident  in  their  practice  has  led  them  to  suspect  that,  in 
spite  of  statistics,  they  are  not  devoid  of  objectionable  or  dangerous 
properties.  In  my  own  experience  during  the  last  sixteen  years,  there 
have  been  comparatively  few  cases  in  which  I  have  not  used  chloroform 
or  ether  in  some  stage  of  labor.  The  result  of  my  experience  has  been 
to  make  me  a  warm  advocate  of  their  wider  employment  on  the  one 
hand,  while  proclaiming  the  necessity  of  caution  in  their  use  upon  the 
other.  It  seems  to  me  that  the  hesitancy  manifested  regarding  their 
general  adoption  is  due,  in  large  measure,  to  the  fact  that  few  practi- 
tioners give  themselves  the  trouble  to  master  the  necessary  modus 
operandi^  to  study  the  limitations  of  their  usefulness,  or  to  learn  the 
conditions  of  their  safe  administration.  It  should  be  steadfastly  borne 
in  mind  that  the  giving  of  anaesthetics  in  labor  is  an  art  to  be  acquired 
— a  very  simple  one,  perhaps,  but  the  practice  of  which  admits  of 
neither  ignorance  nor  carelessness. 

As  in  ordinary  surgical  practice,  auEesthetics  are  contra-indicated  by 
organic  affections  of  the  heart  and  lungs. 

Except  in  the  prolonged  insensibility  required  for  difficult  ob- 
stetrical ojDerations,  I  think  the  preference  should  be  accorded  to 
chloroform  rather  than  to  ether.  The  former  possesses  the  advan- 
tage of  being  more  agreeable,  more  manageable,  and  more  rapid  in  its 
action. 

Ansesthesia,  not  narcosis,  is  the  object  aimed  at,  and  the  dulling 
of  the  sensibility  is  much  more  readily  effected  by  chloroform  than 
by  ether. 

As  a  rule,  chloroform  should  not  be  administered  during  the  first 
stage  of  labor,  partly  because  of  its  tendency,  when  given  at  too  early 
a  period,  to  weaken  the  contractions  of  the  uterus,  and  partly  because 
protracted  anesthesia  has  a  tendency  to  impair  the  cardiac  force.  To 
this  rule  there  are,  however,  numerous  exceptions,  to  which  we  shall 
have  occasion  to  revert  in  connection  with  the  consideration  of  irregu- 
lar labor-pains. 

If  the  pains  in  the  second  stage  are  of  feeble  intensit)^  it  is  best  to 
withhold  the  anesthetic;  if  of  normal  strength,  chloroform  may  be 
given,  but  at  first  only  in  small  doses  and  during  the  continuance  of  a 
pain.  The  anaesthetic  should  not  be  pushed  to  the  stage  of  complete 
unconsciousness  until  the  head  begins  to  emerge  at  the  vulva. 

Chloroform  can  be  conveniently  given  upon  a  folded  handkerchief. 
The  latter  should  be  held  near  to,  but  not  in  contact  with,  the  respir- 
atory passages.  The  best  diluent  for  chloroform,  as  was  long  ago  stated 
by  Sir  James  Simpson,  is  atmospheric  air.  If  the  handkerchief  be  laid 
directly  across  the  nose,  instant  suspension  of  respiration  may  result. 


CONDUCT  OF  NORMAL  LABOR.  227 

A  minor  evil  is  tlie  cutaneous  irritation  produced  by  placing  the  chloro- 
form in  direct  contact  with  the  lips  and  mouth. 

At  the  beginning  of  each  pain  the  patient  should  be  directed  to 
take  a  number  of  deep  inspirations.  During  the  acme  of  the  pain  the 
expiratory  efforts  which  arc  then  called  into  play  prevent  the  inhala- 
tion of  any  considerable  amount  of  the  anaesthetic. 

When  the  head  presses  upon  the  perinaeum,  the  handkerchief  should 
be  intrusted  to  the  nurse,  but  the  administration  to  the  end  should  be 
directed  and  strictly  supervised  by  the  physician. 

When  chloroform  is  first  given,  it  is  common  for  the  pains  to  become 
weakened ;  but  this  suspensive  influence  upon  the  uterus  is  usually 
temporary.  Exceptionally,  however,  the  weakness  of  the  pains  may 
continue,  and  render  it  necessary  to  withhold  the  anesthetic.  In  still 
rarer  cases  the  pains  remain  inefficient  after  the  antesthesia  has  subsided. 
On  this  account  it  seems  to  me  certain  that  those  who  use  chloroform 
habitually  will  find  themselves  compelled  to  resort  to  the  forceps  with 
somewhat  increased  frequency.  A  tardy  labor,  due  to  uterine  inertia, 
will  likewise  call  for  additional  vigilance  during  the  stage  of  placental 
expulsion  to  forestall  the  occurrence  of  hemorrhage. 

The  immunity  enjoyed  by  women  in  childbirth  against  the  accidents 
which  sometimes  occur  from  anaesthesia  in  surgical  practice  is  not  abso- 
lute, but  dependent  upon  its  cautious  and  intelligent  administration.  I 
once  narrowly  escaped  losing  a  patient  in  the  Bellevue  Hospital,  upon 
whom  I  designed  to  perform  version,  in  consequence  of  my  house  phy- 
sician suddenly  crowding  a  paper  funnel  containing  a  towel  wet  with 
chloroform  over  the  respiratory  passages. 

Chloroform  should  not  be  given  in  the  third  stage  of  labor.  The 
relative  safety  of  chloroform  in  parturition  ceases  with  the  birth  of  the 
child.  x\fter  delivery  it  favors  the  relaxation  of  the  uterus  and  predis- 
poses to  hEemorrhage.  Moreover,  after  the  uterus  has  been  emptied 
there  is  always  an  increase  of  blood  in  the  large  vessels  of  the  abdomen, 
and  a  corresponding  recession  of  blood  from  the  head.  Xow,  it  is 
known  that  the  quantity  of  chloroform  which  one  day  is  perfectly  tol- 
erated by  an  individual  in  health  may  prove  fatal  on  the  succeeding  day, 
in  case  of  the  intervention  of  any  considerable  loss  of  blood.  Cerebral 
anasmia,  from  any  cause,  increases  the  risk  of  anesthesia. 

In  lengthy  operations  requiring  prolonged  anesthesia,  ether,  as  has 
already  been  intimated,  should  be  preferred  to  chloroform. 


223  LABOR. 

CHAPTER   XII. 

MULTIPLE  PREGNANCIES  AND   THEIR  MANAGEMENT 

Frequency.— Origin.— Varieties.— Auardia.— Weight.— Unequal  develupment.— Su- 
perfetation.— Diagnosis.— Labor.—  Presentations.—  .Simultaneous  entrance  of 
both  children  into  the  pelvis.— Locking.— Prognosis.— Conduct  of  labor. 

The  term  midtiple  pregnancy  is  used  when  more  than  one  germ 
are  simultaneously  developed.  Twins,  the  most  common  form,  occur 
in  the  proportion  of  one  to  between  eighty  and  ninety  births ;  triplets 
in  about  the  proportion  of  one  to  seven  thousand;  quadruplets  and 
quintuplets  are  of  extreme  rarity.  No  authentic  example  of  over  five 
children  at  a  birth  is  on  record.  An  instance  of  quintuplets  I  have 
once  witnessed.  In  the  Prussian  statistics  of  Von  Hemsbach  and  Veit 
based  upon  thirteen  million  births,  the  number  of  twin  pregnancies 
amounted  to  150,000.  Of  these,  in  50,000  both  children  were  boys ;  in 
46,000  both  were  girls  ;  and  in  54,000  the  children  consisted  of  a  boy 
and  a  girl. 

Twins  may  develop  either  from  two  distinct  ova,  discharged  from  the 
same  or  from  distinct  Graafian  follicles,  or  may  both  originate  from  a 
single  ovum.  If  two  Graafian  follicles  rupture,  the  ovaries  will  offer 
two  corpora  lutea.  In  some  instances  a  corpus  luteum  has  been  found 
in  each  ovary  ;  in  others  both  are  situated  in  the  same  ovary. 

In  the  case  where  twins  develop  from  two  ova,  each  foetus  is  con- 
tained in  its  own  chorion.  If  the  ova  are  imbedded  in  the  decidua  at 
sufficiently  distant  points,  the  placentae  will  be  separate,  and  each  ovum 
will  have  its  distinct  reflexa.  If  near  one  another,  the  placentas  are 
often  united  at  their  borders,  each,  however,  maintaining  its  independ- 
ent circulation.  In  some  cases  the  two  ova  lie  so  close  together  that 
they  are  encircled  by  a  common  reflexa. 

When  twins  are  developed  from  two  centers  contained  in  the  same 
ovum,  the  placenta,  the  chorion,  and  reflexa  are,  of  course,  common  to 
both.  In  most  instances  each  foetus  is  contained  in  its  own  amnion. 
Occasionally,  however,  twins  are  furnished  with  but  one  amnion — a 
peculiarity  which,  in  some  cases  at  least,  is  not  primary,  but  the  re- 
sult of  an  absorption  of  the  party-wall  between  two  originally  distinct 
cavities.* 

Twins  from  the  same  ovum  are  always  of  the  same  sex.  Anasto- 
moses of  greater  or  less  extent  exist  between  the  placental  vessels  of 
the  two  embryos.  The  consequences  of  these  communications  are  of 
the  utmost  importance,  for,  when  extensive,  the  heart's  action  in  one 

*  Ahlfeld,  Beitrage  zur  Lehre  von  den  Zwillingen,  Arch.  f.  Gynaek.,  Bd.  vii, 
p.  281. 


MULTIPLE  PREGNANCIES   AND   THEIR   MANAGEMENT.      229 

foetus  counterbalances  that  of  the  other  ;  the  stronger  blood-current  in 
the  placenta  pushes  back  the  weaker  one,  at  first  impeding  the  circula- 
tion of  the  less  favored  fcetus,  then  arresting  it,  and  finally  causing  it 
to  reverse  its  direction.  The  heart  atrophies,  and  an  acardia  is  pro- 
duced, which  is  simply  an  appendage  to  the  healthy  foetus.  The  cir- 
culation in  the  acardia  takes  place  as  follows  :  Venous  blood  from  the 
healthy  foetus  is  conveyed  by  the  umbilical  arteries  to  the  placenta ;  the 
force  of  the  fetal  heart  drives  the  stream  through  the  communicating 


Fig.  125.  -  Twin  placenta,  sliowin^  arterial  anastomosis. 


branches  to  the  umbilical  arteries  of  the  less  favored  twin  ;  this  force 
is,  however,  insufficient  to  carry  the  current  to  the  upper  parts  of  the 
body,  which  are,  therefore,  not  developed.  The  favorable  position  of 
the  lower  extremities  for  receiving  the  blood  from  the  umbilical  vessels 
explains  their  continued  though  imperfect  growth  and  development. 
The  blood  carried  to  the  foetus  by  the  umbilical  arteries  is  returned  by 
the  umbilical  vein. 

According  to  Ahlfeld,*  a  division  may  take  place  in  the  formative 
material  contained  within  a  single  area  germinativa.      This  division 

*  Ahlfelp,  Die  Entstehung  der  Doppelbildung  und  der  liomologen  Zwillinge, 
Arch.  f.  Gynaek.,  Bd.  ix,  p.  196. 


230 


LABOR. 


may  be  complete,  and  thus  produce  separate  twins  inclosed  in  the 
same  amnion,  which  not  only  are  of  the  same  sex,  but  bear  to  one 
another  through  life  the  most  striking  similarity  as  regards  appear- 
ance, physical  peculiarities,  and  both   mental  and  moral  characteris- 


I 


Fig.  126.— Author's  case  of  acardia.    The  monstrosity  weighed  tliree  pounds  nine  ounces ; 
there  were  no  traces  of  heart,  lungs,  pancreas,  liver,  spleen,  or  sternum. 


tics ;  or  it  may  be  incomplete,  and  thus  give  rise  to  conjoined  twins, 
or  one  of  the  numerous  forms  of  double  monsters.* 

In  triplets,  it  is  common  to  find  one  child  derived  from  an  inde- 
pendent ovum  and  two  from  a  single  ovum.     In  a  case  of  quadruplets 

*  Schultze,  on  the  other  hand,  contends  that  the  double  monsters  are  derived 
from  the  fusion  of  two  embryos  developed  upon  the  blastodermic  vesicle  at  points 
close  to  one  another.  Schultze.  Ueber  Zwillingsschwangerschaft,  Volkmann's 
Samm.  klin.  Vortr.,  No.  34. 


MULTIPLE    PREGNANCIES   AND   TIIKIK    MANAGEMENT.       231 

reported  by  P.  i\Inller,*  two  ova  were  simple,  while  the  third  contained 
two  embryos.  The  children  in  the  single  ova  were  of  the  female 
while  those  in  the  double  ovum  Avere  of  the  male  sex. 

The  average  weight  of  the  individual  children  in  multiple  preg- 
nancies is  less  than  that  of  children  born  single.  This  is  partly  due 
to  the  frequency  with  v/hich  the  excessive  distention  of  the  uterus 
becomes  the  exciting  cause  of  premature  delivery,  and  partly  to  the 
obvious  fact  that  the  maternal  organism  is  rarely  capable  of  furnishing 
the  nutritive  material  requisite  for  the  complete  growth  of  more  than 
a  single  child. 

Twins  often  exhibit  at  birth  a  remarkable  disparity  as  regards  both 
size  and  development — a  disparity  unquestionably  due  to  local  condi- 
tions. A  striking  example  of  this  is  shown  in  a  case  related  by 
Schultze.f  One  child,  at  the  time  of  delivery,  was  nearly  if  not  quite, 
mature,  while  the  other  presented  the  appearances  of  a  six  weeks' 
fcetus.  As  both  ova  were  enveloped  in  the  same  reflexa,  their  develop- 
ment mast  have  begun  at  nearly  the  same  time. 

Sometimes  one  foetus  dies,  and  yields  to  the  more  fortunate  brother 
the  space  and  the  nutritive  material  which  would  otherwise  have  fallen 
to  his  share.  In  such  a  case  the  ovum  and  the  contained  fa?tus  may 
be  compressed  by  the  surviving  twin,  and  be  flattened  against  the 
uterine  wall,  giving  rise  to  the  so-called  "  foetus  papyraceus  " ;  or  it 
may  degenerate  into  a  mole  ;  or  the  aborted  ovum  may  be  exjselled, 
while  the  living  foetus  advances  to  the  full  term  of  gestation. 

Very  rarely,  where  the  twins  are  both  living  but  have  undergone 
unequal  development,  the  stronger  child  may  be  delivered  first,  \\'hile 
the  other  remains  in  the  uterus,  and  is  born  after  weeks  of  delay,  dur- 
ing which,  under  more  favorable  conditions,  it  makes  good  the  defi- 
ciencies due  to  its  retarded  evolution.  The  most  remarkable  cases  of 
this  kind  occur  in  the  uterus  duplex.  Professor  Fordyce  Barker  re- 
lated an  instance  in  his  practice  where,  in  a  double  uterus,  a  mature 
living  male  child  was  born  on  the  10th  of  July,  1855,  and  on  the  2.2d  of 
September  following  the  mother  gave  birth  to  a  full-term  living  girl. 

Histories  like  the  foregoing  are  often  adduced  in  support  of  the 
theory  of  what  is  known  as  superfetation — a  theory  which  supposes 
that,  aftcx  conception  has  once  occurred,  a  second  gestation  may  result 
from  a  subsequent  coitus.  That  this  is  possible,  if  two  ova  are  de- 
tached during  the  same  menstrual  period,  seems  to  be  established  by 
authentic  accounts  of  negro  women  giving  birth  to  twins,  showing  the 
evidences  of  a  paternity  derived  in  one  from  the  black  and  in  the 
other  from  the  white  race.  That  impregnation  can  take  place  at  two 
periods  distant  from  one  another  must  be  regarded  as  an  inadmissible 

*  P  MiJLLER,  Eine  Vierling's  Geburt,  Ztschr.  f.  Geburtsh.  uiul  Gynack..  IM.  iii, 
p.  166. 

f  SCHULTZE,  loc.  cit.,  p.  308. 


232  LABOR. 

hypothesis,  until  physiologists  shall  succeed  in  demonstrating  in  a  sin- 
gle instance,  by  the  presence  of  corpora  lutea  of  different  ages,  that 
ovulation  ever  occurs  during  pregnancy. 

Diagnosis. — The  diagnosis  of  multii^le  pregnancy  is  rarely  to  be 
made  out  with  absolute  certainty.  Unusual  dze  of  the  uterus,  with 
exaggeration  of  the  syhiptoms  which  result  from  pressure,  would  nat- 
urally lead  to  inquiry  on  the  part  of  the  physician,  as  it  is  certain  to 
excite  uppreliensions  in  the  mind  of  the  pregnant  female.  (Size,  how- 
ever, furnishes  but  an  uncertain  criterion,  as  it  may  be  equally  due  to 
the  presence  of  a  very  large  child,  or  to  an  excess  of  amniotic  fluid. 
More  trustworthy  information  is  to  be  obtained  from  palpation  and 
auscultation.  Thus  the  recognition  of  a  number  of  distinct  fetal  parts 
and  the  exclusion  of  hydramnion  would  render  tlie  diagnosis  of  twin 
pregnancy  probable.  The  outlining  of  two  fetal  heads  at  a  distance 
from  one  another  would  make  the  diagnosis  certain.  When  the  fetal 
heart  is  heard  at  two  remote  points,  and  the  sound  is  found  to  die 
away  in  the  intervening  space,  it  is  justifiable  to  conclude  that  the 
sound  at  each  point  has  a  separate  origin.  If  the  two  heart-beats 
are  counted  at  the  same  time  by  different  observers,  and  are  found 
not  to  correspond  in  frequency,  a  twin  pregnancy  is  established  be- 
yond dispute.  After  the  birth  of  the  first  child,  the  presence  of  the 
second  is  determined  by  the  size  and  consistence  of  the  uterus,  and  the 
perception  of  fetal  parts  both  through  the  abdominal  walls  and  tlie 
vagina. 

The  recognition  of  triplets  and  quadruplets  is,  of  course,  attended 
with  even  greater  difficulties  than  that  of  twins. 

Labor  in  Multiple  Pregnancies.— We  have  already  noticed  the  fre- 
quency of  ])remature  labor  in  multiple  pregnancies.  Of  one  hundred 
and  ninety-two  twin  births  reported  by  Reuss*  from  the  AViirzburg 
clinic,  fifty-one  did  not  complete  the  full  term  of  gestation.  In  one 
of  these  abortion  resulted  from  small-pox,  in  another  from  syphilis,  in 
two  cases  premature  labor  was  induced  artificially,  in  the  others  labor 
occurred  spontaneously — in  one  instance  at  the  seventh  month,  in  the 
other  in  the  ninth  or  tenth  months. 

Twin  labors  are  usually  easy.  The  first  child  is  delivered  as  in 
simple  labors,  and,  except  in  faulty  presentations,  is  followed  shortly 
by  the  second.  The  interval  varied,  in  seventy-four  of  Reuss's  cases 
which  terminated  spontaneously,  from  five  minutes  to  one  and  a  half 
hour.  In  seventy-nine  per  cent  the  interval  was  less  than  an  hour. 
As  the  stage  of  dilatation  is  completed  at  the  time  of  the  expulsion  of 
the  first  twin,  a  protracted  interval  is  occasioned  purely  by  weakness 
and  inefficiency  of  the  pains. 

The  placenta?  are  usually  expelled  after  the  birth  of  the  second 
child  ;  now  and  then  tlie  placenta  of  the  first  child  precedes  the  birth 
*  Reuss,  Znr  Lehre  von  den  Zwillingen,  Arch.  f.  Gynaek.,  Bd.  iv,  p.  123. 


I 


MULTIPLE   PREGNANCIES   AND   THEIR  MANAGEMENT.      233 

of  the  second  ;  again,  the  second  child  may  not  be  born  until  after  the 
delivery  of  its  placenta.  When  the  placenta  are  united,  a  portion  may 
be  torn  off  and  expelled  with  the  first  child,  while  the  remainder  is  not 
thrown  off  until  after  the  birth  of  the  second.*  The  placental  stage 
is,  owing  to  the  relaxed  state  of  the  uterine  walls,  apt  to  be  of  longer 
duration  than  in  simple  labors,  and  calls  for  the  exercise  of  special 
care  to  guard  against  the  occurrence  of  hemorrhage. 


Fig.  127.— Twin  pregnancy,  both  heads  presenting.    (Tarnier  et  Chantreuil.) 


Presentations  in  Twin  Labors.— Spiegelberg  f  furnishes  the  follow- 
ing table,  derived  from  1,138  deliveries,  of  which  899  were  taken  from 
Kleinwiichter  and  203  from  Reuss  : 

Both  heads  presenting 558, 

Head  and  breech  presenting 361, 

Both  pelvic  presentations 98, 

Head  and  transver.se  presentations.  ...      ...     71, 

Breech  and  transverse 46, 

Both  transverse 4, 


or  49 

per  cent. 

"    31-7 

"      8-6 

"      618 

"      4-14 

"      0-35 

Vide  SpiEGELBERCi,  Lehrbuch  der  Geburtshiilfe.  Bd.  i,  p.  203. 


t  Ibid. 


234 


LABOR. 


The  transverse  presentations  are  mostly  secondary,  consequent 
upon  the  roominess  of  the  uterine  cavity  and  the  sudden  escape 
of  the  amniotic  fluid.  Version  is,  of  course,  in  such  cases  easily  per- 
formed. 

The  Simultaneous  Entrance  of  Both  Children  into  the  Pelvis.— The 
consideration  of  the  various  complications  to  which  this  anomaly  gives 
rise  belongs  to  the  domain  of  pathology.  To  avoid,  however,  needless 
repetitions,  they  may,  for  convenience'  sake,  be  properly  considered  in 
the  present  connection. 

AVheu  both  children  present  at  the  brim  previous  to  the  rupture  of 
the  membranes,  it  usually  happens  that,  with  the  escape  of  the  amni- 
otic fluid,  one  of  the  twins  descends  into  the  pelvis,  while  the  second 
glides  to  one  side.  The  result  is  identical,  whether  the  twins  are  con- 
tained in  a  single  or  in  separate  sacs.  If  interference  is  called  for 
because  of  delay,  the  amnion,  or  one  amnion  in  case  there  are  two, 
should  be  ruptured,  and  the  nearest  presenting  part  brought  into  the 
pelvis,  while  the  other  is  at  the  same  time  pushed  out  of  the  way. 
If -head  and  breech  present,  the  head  should  preferably  be  allowed  to 
descend  first. 

It  may  happen,  however,  that  after  rupture  both  children  may 
descend  into  the  pelvis  so  close  to  one  another  as  to  hinder  each  the 
other  in  its  further  progression.  This  locking  of  the  twins,  as  it  is 
termed,  may  take  place  in  one  of  two  ways,  viz.  : 

1.  In  double  vertex  presentations,  delivery  may  be  impeded  by  the 
pressing  of  the  second  head  into  the  neck  of  the  more  advanced  foetus, 
or,  after  the  birth  of  the  first  head,  the  second  may  enter  the  pelvis 
and  arrest  the  advance  of  the  thorax.  Obviously  this  difficulty  could 
only  arise  in  a  case  where  both  heads  were  of  unusually  small  size. 
The  diagnosis  has  rarely  been  made  previous  to  the  birth  of  the  first 
head.  The  treatment  consists  in  the  artificial  extraction  of  one  head 
after  the  other,  and  then  delivering  the  body  of  the  first  child.  Cra- 
niotomy is  usually  not  necessary.  The  prognosis  as  regards  the  chil- 
dren is  extremely  unfavorable.  Eeimann  *  reports  six  cases  in  which 
the  fate  of  the  children  was  known.  Of  the  six  first-born,  one  sur- 
vived; of  the  six  last-born,  two  survived.  Reimann,  in  commenting 
on  these  figures,  remarks :  "  The  child  whose  head  first  enters  the  pel- 
vis is  in  great  danger,  because  not  only  is  its  neck  squeezed  by  the 
head  of  the  second  child,  thereby  producing  cerebral  hyperaemia,  but 
its  umbilical  cord  is  exceedingly  liable  to  be  compressed  by  the  body 
of  the  second  child."     ■ 

2.  When  one  child  presents  by  the  breech,  the  other  by  the  vertex, 
the  former,  because  of  its  smaller  size,  is  apt  to  descend  first  into  the 
pelvis.  No  difficulty  is  then  experienced  until  the  neck  is  born.  In 
case,  however,  meantime  the  head  of  the  second  child  has  entered  the 

*  Reimans.  Am.  .Jour,  of  Obstet.,  1877,  vol.  i.  p.  .58. 


MULTIPLE   PREGNANCIES  AND  THEIR  MANAGEMENT.      235 

pelvis,  further  progress  may  be  rendered  impossible,  a  lock  resulting 
either  from  the  overlapping  of  the  chins,  or  of  the  occipital  portions 
of  the  two  heads,  or  from  the  pressure  of  the  face  of  one  child  into 
the  neck  beneath  the  occiput  of  the  other.  By  lifting  the  body  of  the 
child,  and  introducing  the  half-hand  into  the  vagina,  the  diagnosis  is 
rendered  easy. 

In  a  large,  roomy  pelvis,  if  the  pains  are  good  and  the  children 
small,  spontaneous  delivery  may  take  place.     In  a  number  of  cases  of 


Fig.  128.— Twill  pregnancy,  head  and  breech  presenting.    (Tarnier  et  Chantreuil.) 


this  kind  which  have  been  reported,  the  head  of  the  second  child  was 
born  first.  In  a  few  instances  it  has  been  found  possible  to  push  up 
the  second  head.  Operative  measures  consist  in  applying  the  forceps 
and  extracting  the  second  head,  and  afterward,  if  necessary,  the  first. 
In  case  of  failure,  craniotomy  remains  as  an  ultimate  resort.  The  first 
child  is  rarely  born  living.  Of  twenty-six  children,  the  fate  of  which 
was  ascertained  by  Reimann,  only  three  survived.  The  prognosis  of 
the  second  child  is  more  favorable.  Of  twenty-nine  cases,  Reimann 
reports  nineteen  survivals.      Xaturally,  therefore,  the   perforation  of 


236 


LABOR. 


the  first  head  would  be  preferred,  were  the  matter  one  purely  of  elec- 
tion, but  the  operation  is  very  difficult,  and  does  not  remove  the  ob- 
stacle, for  even  the  diminished  head  can  not  pass  the  one  already 
occupying  the  pelvis.*  In  the  cases  so  far  reported,  where  decapita- 
tion of  the  first  child  has  been  performed,  the  operation  has  not  proved 
successful  in  saving  the  life  of  the  second. 

The  possibility  of  one  twin  sitting  astride  the  other,  when  trans- 
verse, requires  mention,  because  of  the  perplexity  that  may  arise  as  to 
the  diagnosis,  unless  the  hand  is  introduced  into  the  lower  segment 
of  the  uterus  to  determine  the  exact  relations  of  the  twins  to  one 
another. 

Prognosis. — The  prognosis,  both  as  regards  the  children  and  the 
mother,  is  much  more  unfavorable  than  in  simple  labors.  Statistics 
on  this  point  are  valueless,  as  much  depends  upon  the  conduct  of  the 
physician.  As  regards  the  children,  the  increased  mortality  results 
from  prematurity,  from  unequal  development,  and  from  the  frequency 
of  malpositions  and  malpresentations,  requiring  operative  interference. 
As  regards  the  mother,  the  mortality  and  susceptibility  to  puerperal 
diseases  are  augmented  by  the  excessive  distention  of  the  uterus,  the 
extent  of  the  placental  wound,  the  feebleness  in  many  cases  of  uterine 
retraction  after  delivery,  and  by  the  operations  which  grow  out  of  the 
anomalies  to  which  labor  in  multiple  pregnancies  is  subjected. 

Conduct  of  Labor  in  Multiple  Pregnancies. — The  management  of 
multiple  pregnancies  does  not  dift'er  essentially  from  that  of  ordinary 
labor.  After  the  birth  of  the  first  child,  the  placental  end  of  the  cord 
should  in  all  cases  be  tied,  on  account  of  the  frequency  with  which 
anastomoses  are  found  between  the  vessels  of  the  placentae.  A  period 
of  repose  should  then  be  allowed,  to  enable  the  uterus  to  retract  down 
upon  the  remaining  ovum.  During  the  birth  of  the  second  child, 
every  care  should  be  taken  to  follow  the  uterus  with  the  hand,  and 
redoubled  precautions  should  be  observed  against  the  occurrence  of 
haemorrhage,  to  which  the  woman  is  exposed  both  on  account  of  the 
large  size  of  the  placental  wound  and  the  disposition  to  relaxation. 
In  case  the  second  child  presents  by  the  shoulder,  version  by  external 
manipulations  alone  is  usually  practicable.  Expression  should  be  em- 
ployed to  force  the  placentae  into  the  vagina.  When  both  descend  at 
once,  if  it  is  necessary  to  make  tractions,  both  cords  should  be  drawn 
upon,  simultaneously  or  in  alternation,  to  find  which  placenta  is  most 
easily  removed.  When  one  placenta  follows  the  birth  of  the  first  child, 
it  should  be  left  untouched  until  the  advent  of  the  second.  Vigilance 
after  delivery  should  be  long  observed. 

We  have  already  noticed  that  the  length  of  time  between  the  ex- 
pulsion of  twins  situated  in  separate  membranes  rarely  exceeds  an 
hour.     When,  therefore,  there  is  a  longer  delay  in  the  delivery  of  the 

*  Reimann,  ioc.  cU..  p.  61. 


I 


MULTIPLE   PREGNANCIES  AND   THEIR  MANAGEMENT.      2?>T 

second  child,  measures  should  be  employed  to  excite  pains,  and  the 
membranes  should  be  ruptured.  In  case  of  a  premature  child  deliv- 
ered with  its  own  placenta,  cases  of  continued  deVelopment,  in  utero, 
of  the  remaining  child,  would  point  to  the  policy  of  abstention.  In 
instances  where  more  than  two  children  are  contained  in  the  uterus, 
the  anomalies  of  position  are  more  frequent,  and  the  danger  of  hsemor- 
rhage  is  still  further  enhanced.* 

*  Spiegelberu,  Lehrbuch.  pp.  206,  307. 


THE  PUERPERAL  STATE. 


CHAPTER   XIII. 

THE  PHYSIOLOGY  AND  3IANAGEMENT  OF  CHILDBED. 

The  puerperal  state  borders  closely  upon  pathological  conditions.— Post-parlum 
chill.— Temperature.— The  pulse.— General  functions.— Retention  of  urine.— 
Loss  of  weight.— Involution.— Separation  of  the  decidua.— Closure  of  tlie 
sinuses.— The  cervix.— The  vagina.— Position  of  uterus.— After-pains.— The 
lochia.— The  secretion  of  milk.— Anatomical  considerations.  — Milk-fever. — 
Composition  of  milk.— Diagnosis  of  the  puerperal  state.— The  new-born  in- 
fant.—Changes  in  circulation.— The  navel.— Tumor  upou  the  presenting  part, 
—Digestion.— Skin.— Icterus.  —  Loss  of  weight.  — Management  of  puerperal 
state.— Sleep.— Passing  urine.— Visits  of  physician.— Washing  the  vagina.— 
Diet.— Laxatives.— Nursing.— Duration  of  lying-in  period.— Care  of  new-born 
infant.— Bath.— Cord.— Nursing.— Wet-nurses.— Artificial  feeding. 

The  puerperal  state  occupies  the  border-land  between  health  and 
disease.  Though  in  a  strict  sense  physiological,  it  otters  a  variety  of 
conditions,  as  Schroeder  *  has  pointed  out,  whicli  at  other  times,  and 
under  other  circumstances,  would  be  regarded  as  pathological.  Thus, 
the  exfoliation  of  the  decidua,  and  the  copious  serous  transudation, 
with  the  abundant  formation  of  young  cells  which  accompanies  the 
development  of  the  new  mucous  membrane,  would  elsewhere  be  re- 
garded as  characteristic  features  of  catarrhal  inflammation.  The  acute 
degeneration  of  the  uterus  presents  a  phenomenon  which,  when  re- 
peated in  any  other  organ  of  the  body,  would  prove  speedily  fatal. 
The  thrombus  formation  in  the  open  placental  vessels  possesses  no 
corresponding  physiological  analogue.  Again,  the  torn  vessels  may 
lead  to  haemorrhage,  while  the  traumata  which  even  in  normal  labor 
result  from  parturition,  the  ease  with  which  deleterious  materials  are 
absorbed  by  the  wide  lymphatic  interspaces,  the  serous  infiltration  of 
the  pelvic  tissues,  the  exaggerated  size  of  the  lymphatics  and  veins, 
create  a  predisposition  to  innumerable  forms  of  disease.  The  nicety 
of  the  balance  between  normal  and  morbid  conditions  renders  it  pecul- 
iarly necessary  for  the  practitioner  to  make  himself  familiar  with  the 
physiological  limits  of  the  phenomena  of  childbed. 

Post-partum  Chill. — The  exertion  of  labor  is  followed  by  a  sense  of 
comfort  and  repose.     Often,  after  the  birth  of  the  child,  a  chill  sets  in 

*  Schroeder,  Handbuch  der  Geburtsliiilfe,  6te  Aufl.,  p.  216. 


THE  PHYSIOLOGY  AND  MANAGEMENT  OP  CHILDBED. 


239 


of  greater  or  less  intensity,  but  of  short  duration,  and  of  no  prof^nostic 
importance.  It  is  to  be  accounted  for  by  the  disturbance  of  the 
equilibrium  between  the  internal  temperature  and  that  of  the  external 
surface.  Thus,  toward  the  end  of  labor,  and  for  a  short  period  sub- 
sequent to  delivery,  the  loss  of  heat  is  increased  by  the  evaporation 
from  the  lungs  and  skin  and  the  cessation  of  muscular  effort.  This 
cooling  process  is,  however,  speedly  arrested  by  the  contraction  of  the 
cutaneous  arterioles.  During  the  period  which  intervenes  until  the 
external  and  internal  temperatures  rise  to  relatively  equal  levels,  the 
l)atient  experiences  chilly  sensations,  or  a  distinct,  well-defined  chill* 
This  phenomenon  is  more  frequent  in  hypera^sthetic  women  and  in 
those  whose  skins  are  bathed  in  profuse  perspiration,  especially  where 
there  has  been  some  necessary  exposure  of  the  person  during  the  ex- 
pulsion of  the  head  or  of  the  placenta.  Under  the  influence  of  a 
warm,  dry  bed,  the  chill  at  once  subsides. 

Temperature. — As  a  rule,  it  may  be  stated  that  the  temperature 
range  in  normal  childbed  does  not  differ  materially  from  that  which 
prevails  in  non-puerperal  conditions.f  Still,  a  rise  of  temperature  fol- 
lowing the  parturient  act,  averaging  one  and  a  half  degree  in  primipara? 
and  one  degree  in  multiparas,  is  not  uncommon.  This  elevation  may 
continue  during  the  first  six  days,  with,  however,  morning  remissions 
and  slight  evening  exacerbations.  It  is  most  pronounced  in  the  first 
twelve  hours,  especially  when  they  coincide  with  the  normal  evening 
increment.  In  the  following  days  the  highest  point  is  usually  reached 
at  five  in  the  afternoon,  while  the  lowest  temperature  is  found  in  the 
night  hours  between  eleven  and  one.  A  sub-febrile  temperature  of 
100^°  has  no  prognostic  significance.  A  temperature  rise  above  100^° 
is  by  no  means  incomjsatible  with  a  generally  satisfactory  condition 
of  the  patient.  Among  the  provoking  causes  of  increased  heat  pro- 
duction may  be  reckoned  prolonged  labor,  fecal  impaction,  mental 
excitement,  the  reaction  of  small  wounds  in  the  course  of  the  geni- 
tal canal,  and  the  disturbances  attendant  upon  the  establisliment  of 
lactation.  J 

The  Pulse.— In  contrast  to  the  increase  in  the  temperature,  the 
pulse  often  exhibits  a  remarkable  diminution  in  frequency,  in  perfectly 
norjnal  cases  ranging  between  sixty  and  seventy  beats,  but  not  unfre- 
quently  dropping  to  a  still  lower  level,  and  may  even  sink  to  less  than 
forty  pulsations  in  the  minute.  This  slowing  of  the  pulse  is  of  favor- 
able prognostic  import.     It  is  known  to  be  associated  with  diminished 

■"•  Fehling,  Klin.  Beobachtungen  Gberden  Einfluss  der  todten  Fruehto  auf  die 
Miitter,  Arch.  f.  Gynaek.,  Bd.  vii,  p.  15L 

•f-  Temesvary  and  Backer,  Studien  aus  dem  Gebiete  des  Woehenbettes,  Arcii.  f. 
Gynaek.,  vol.  xxxiii,  p.  331. 

t  Vidp  ScHROEDER,  Schwangersohaft,  Geburt  und  Wochcnbett,  pp.  168-177; 
SpiEGELBERG,  Lelirbuch.  p.  210. 


240  THE   PUEttPERAL  STATE. 

arterial  teusion,*  and  has  beeu  attributed  to  a  variety  of  not  very  sat- 
isfactory reasons,  such  as  the  sudden  removal  of  the  utero-placental 
vessels  from  the  circulation,  entailing  a  less  degree  of  labor  upon  the 
heart,  repose  in  bed,  and  disturbed  action  of  the  pneumogastric 
nerves.  It  is  usually  most  marked  on  the  second  or  third  day,  and 
does  not  appear  to  be  specially  influenced  by  the  establishment  of 
lactation. 

General  Functions.— During  the  first  week  the  skin  is  active  and 
moist ;  the  patient  is,  therefore,  sensitive  to  temperature  changes,  and 
is  subject  to  profuse  perspiration  when  warmly  covered  or  during  sleep. 
The  appetite  is  lessened,  the  thirst  is  increased,  the  bowels  are  slug- 
gish, and  the  urine  abundant.  In  spite  of  the  light  diet  and  repose 
in  bed,  the  amount  of  urea  eliminated  is  but  slightly  diminished. 
Sugar  in  the  urine  is  observed  at  the  time  of  the  establishment  of  lac- 
tation. It  disappears  soon  afterward,  to  reappear,  however,  whenever 
the  milk  production  is  in  excess  of  its  consumption.!  The  diabetes 
is,  therefore,  due  to  absorption. J 

Retention  of  Urine. — In  the  first  day  or  two  following  confinement, 
retention  of  urine  is  a  common  occurrence.  It  results,  according  to 
Schroeder,  from  the  increased  capacity  of  the  bladder  following  the  re- 
moval of  pressure  from  the  gravid  uterus.  !Many  women  who  suffer 
from  retention  when  reclining  are  able  to  voluntarily  urinate  when 
raised  to  a  sitting  posture,  probably  because  of  the  greater  facility  with 
which,  in  the  latter  case,  the  pressure  of  the  lax  abdominal  parietes  can 
be  exerted  upon  the  bladder. 

Loss  of  Weight. — Owing  to  the  rapid  retrograde  changes  in  the 
pelvic  organs,  the  discharges  from  the  genital  passage,  the  increased 
secretions  of  the  skin  and  kidne3'S,  combined  with  limited  ingestion  of 
food,  the  loss  of  weight  in  the  first  week  amounts  to  from  nine  to  ten 
pounds,  or,  roughly  speaking,  to  about  one  twelfth  the  weight  of  the 
body.* 

Involution. — The  processes  by  means  of  Avhich  the  uterus  returns  to 
its  non-puerperal  condition  are  inaugurated  at  the  commencement  of 
labor.  During  the  rapidly  following  contractions  of  the  uterus  there 
is,  on  the  one  hand,  waste  of  tissue  substance,  engendered  by  the  work 
performed,  while  on  the  other,  the  compression  of  the  nutrient  vessels 
diminishes  the  supply  of  reparative  material.  As  a  result  of  this  dis- 
turbed equilibrium,  there  ensues  a  fatty  degeneration  of  the  protoplasm 
of  the  muscle  cells.  This  process  continues  after  the  expulsion  of  tlie 
ovum.     At  the  same  time,  the  individual  muscular  cells  shorten  and 

*  Meyberg,  Ueber  die  Pulse  der  Wochnerinnen,  Arch.  f.  Gynaek.,  Bd.  xii,  p.  114. 
f  JoHANN'ovsKY,  Ueber  den  Zuckergehalt  im  Harne  der  Wochnerinnen,  Arch.  f. 
Gynaek.,  Bd.  vii,  p.  448. 

X  Spiegelberg,  loc.  cit,  p.  212. 

«  Gassner,  Monatsschr.  f.  Geburtsk.,  Bd.  xix,  p.  47. 


THE  PHYSIOLOGY  AND   MANAGEMENT   OF  CHILDBED.      241 

broaden,  while  transverse  and  longitudinal  ridges  form  iipon  them. 
In  this  way,  and  by  the  absorption  of  the  superfluous  protoplasm,  the 
muscular  cells  are  gradually  reduced  to  normal  dimensions.  In  from 
six  to  eight  weeks  the  process  described  reaches  its  completion.  The 
lochia  then  cease,  and,  in  women  who  do  not  nurse,  menstruation 
returns. 

Tlie  view  maintained  by  Hesclil,  which  long  received  the  support  of  obstet- 
rical writers,  was  in  effect  that  subsequent  to  labor  the  entire  muscular  tissue  of 
the  uterus  underwent  fatty  degeneration,  and  that  the  oxidized  products  were 
gradually  absorbed.  Meantime,  a  new  formation  of  muscular  cells,  beginning 
upon  the  periphery  of  the  organ,  about  the  fourth  week,  took  the  place  of  the 
old  elements.  In  accordance  with  this  view,  it  has  been  customary  to  state 
that  witli  the  end  of  each  pregnancy  the  old  uterus  was  destroyed,  and  that  a 
new  organ  was  built  up  upon  its  ashes.  KoUiker  admitted  a  partial  destruction 
and  a  partial  new  formation  of  muscle  cells,  but  held  that  the  greater  number 
of  the  enormously  enlarged  cells  of  pregnancy  did  not  entirely  disappear. 

The  view  we  have  given  is  that  defended  originally  by  Luschka  and  Robin. 
In  studies  preparatory  to  his  work  on  Caesarean  section,  Sanger  was  perplexed 
to  see  how  union  of  cut  surfaces  could  be  secured  by  means  of  suture  if  the 
theory  of  simultaneous  acute  fatty  degeneration  should  be  proved  correct. 
Careful  observations  made  by  him  upon  this  point  seem  to  settle  the  question 
in  favor  of  the  more  conservative  natural  process.  * 

Immediately  after  birth  the  uterus  weighs  upward  of  two  pounds. 
The  peritoneal  surface  is  covered  with  transverse,  oblique,  and  longi- 
tudinal ridges,  and  furrows  corresponding  to  the  direction  of  the  un- 
derlying muscular  bundles.  In  two  days  the  weight  falls  to  a  pound 
and  a  half ;  the  uterus  is  seven  to  eight  inches  in  length,  and  about 
four  and  a  lialf  inches  broad ;  the  walls  are  from  an  inch  to  an  inch 
and  a  half  in  thickness.  At  the  end  of  a  week  the  uterus  weighs  a 
pound,  and  is  five  to  six  and  a  half  inches  long.  At  the  end  of  two 
weeks  the  weight  is  three  fourths  of  a  pound,  the  length  five  inches, 
and  the  walls  hardly  a  half-inch  in  thickness.  Of  course,  the  indi- 
vidual variations  from  these  averages  are  very  great,  f  In  six  weeks 
the  process  usually  reaches  the  end,  though  the  uterus  remains  ever 
after  somewhat  larger  and  more  rounded  than  in  nulliparae— a  change 
due  chiefly  to  an  increase  of  connective  tissue. 

Repair  of  the  Decidua.— With  the  expulsion  of  the  ovum  the  outer 
portion  of  the  decidua  vera  for  the  most  part  adheres  closely  to  the 
reflexa,  while  the  meshy  portion,  with  the  fundi  of  the  glands,  remains 
attached  to  the  uterus.  The  adherent  portion  consists  of  empty  areolar 
spaces,  of  gland  septa,  of  lymphatic  spaces   and  blood-vessels,  while 

*  Vide  The  Involution  of  the  Muscular  Tissue  of  the  Puerperal  Uterus,  by  Dr. 
M.  Sanger,  Annals  of  Gynjecology,  Boston,  July,  1888. 

f  BoRNER,  Ueber  deri  puerperalen  Uterus ;  Sinclair,  Measurements  of  the  Uter- 
ine Cavity,  Trans,  of  the  Am.  Gynaec.  Soc,  vol.  iv,  p.  231. 
Ifi 


242  THE  PUERPERAL  STATE. 

only  the  fundal  extremities  are  liued  with  glandular  epithelium.*  As, 
however,  the  line  of  demarkation  rarely  takes  place  throughout  the 
entire  decidua  at  any  fixed  level,  fragments  of  the  outer,  more  com- 
pact layer  may  frequently  be  found  here  and  there  clinging  to  the 
inner  surface  of  the  residual  membrane.f 

The  uterine  cavity  is  covered  and  in  part  filled  with  at  first  a  bloody 
and  subsequently  a  muco-sanguinolent  fluid  containing  blood  and  mu- 
cus corpuscles,  and  decidua-cells  in  various  stages  of  degeneration. 

At  the  end  of  a  week  the  mucous  membrane  measures  at  most  from 
a  half  to  three  quarters  of  a  line  in  thickness ;  the  inner  surface  has 
become  smoother  from  the  disintegration  and  exfoliation  of  adherent 
shreds ;  the  glands,  owing  to  diminished  size  of  the  uterus,  are  pressed 
closer  together,  and  assume  a  more  nearly  perpendicular  direction  ;  the 
gland-epithelium  extends  upward  along  the  gland-walls  to  the  surface 
of  the  membrane ;  the  interglandular  sjjaces  are  filled  with  lymphoid 
cells,  with  blood-corpuscles,  fat-granules,  and  epithelial  cells,  in  a  state 
of  fatty  degeneration.  As  the  regenerative  process  goes  on,  fine  capil- 
laries Avithout  walls  form  in  the  interglandular  substance,  so  that  the 
latter  jn'esents  the  appearance  of  granulation -tissue.  By  the  third  week 
these  vessels  of  new  formation  stretch  upward  to  the  surface  of  the 
mucous  membrane,  and  by  the  sixth  week  the  development  of  the  vas- 
cular network  is  complete.  In  the  second  week  the  lymphoid  cells 
begin  to  dissolve,  and  thus  the  glands  are  brought  into  near  contact 
with  one  another.  Spindle-shaped  cells  of  young  connective  tissue 
are  formed  between  the  glands  in  the  second  week,  and  with  continued 
connective-tissue  jjroliferation  the  flattened  tubules  arc  drawn  upward, 
and  assume  a  perpendicular  direction.  The  epithelial  cells  at  the 
mouths  of .  the  glands,  which  at  first  formed  separate  islets,  approach 
one  another  as  the  glands  assume  their  normal  positions,  and  by  act- 
ively multiplying  spread  from  the  circumference  until  they  form  a 
continuous  lining  to  the  wounded  surface. 

As  regards  tlie  principal  features,  the  changes  which  take  place  at 
the  placental  site  are  the  same  as  those  described  elsewhere  Avithin  the 
uterine  cavity.  Immediately  after  delivery,  however,  the  surface  pos- 
sesses an  uneven  aspect,  with  elevations  where  the  septa  of  the  serotina 
had  penetrated  between  the  placental  cotyledons,  and  with  intervening 
depressions.  The  mouths  of  the  torn  vessels  are  closed  by  thrombi, 
and  large  vessels  are  irregularly  distributed  beneath  the  attached  resi- 
due of  the  mucous  membrane.  The  process  of  regeneration  at  the 
placental  site  takes  place  somewhat  more  slowly  than  elsewhere  within 
the  uterus. 

*  Leopold,  Studien  iiber  die  Uterusschleimhaut,  etc.,  Arch.  f.  Gynaek.,  Bd.  xii, 
p.  180. 

t  KiJsTNER,  Die  LOsung  der  miitterlichen  Eihaute,  Arch.  f.  Gynaek.,  Bd.  xiii 
p.  422. 


THK    PHYSIOLOGY   A\I)    MANAGEMENT   OF   CHILDBED.       9+3 

Closure  of  the  Sinuses.— Bv  tlie  eighth  montli  of  pregnancy,  as  has 
been  mentioned,  a  portion  of  the  sinuses  beneatli  the  placenta  are  oblit- 
erated by  the  emigration  of  giant-cells  which  cause  coagulation  of  the 
blood  circulating  through  them.  After  delivery,  the  blood  stagnates 
in  the  intact  vessels  in  such  a  way  that  at  first  the  inner  walls  are 
covered  with  fibrin,  while  the  center  contains  fresh  red  blood.  The 
walls  then  thicken  by  proliferation  of  the  endothelium,  and  lymph - 
and  blood -corpuscles  penetrate  into  the  coagulated  layer.  Finally,  the 
thrombus  fills  the  entire  vessel,  spindle-shaped  cells  radiate  from  the 
endothelium,  and  with  the  development  of  young  connective  tissue  a 
gradual  shrinkage  takes  place,  which,  however,  proceeds  slowly,  so  that 
four  to  five  months  after  birth  the  placental  site  is  still  distinguishable.* 
According  to  Eugehuann,  pigmentary  deposits  in  the  tissue  of  the 
mucous  membrane  are  almost  conclusive  evidence  of  recent  delivery, 
as  after  menstruation  they  are  not  found,  probably  on  account  of  the 
superficial  chai'acter  of  the  haemorrhage. 

The  Cervix.— After  delivery  the  cervix  speedily  resumes  its  normal 
size.  At  first  it  has  a  soft  and  pulpy  feel.  The  os  internum  forms  a 
resistant  ring,  which  constitutes  a  well-defined  boundary  between  the 
corpus  and  cervix  uteri.  This  ring  varies  in  size  in  different  subjects, 
but  is  always  sufficiently  o])en  to  permit  the  introduction  of  two  fingers. 
Beneath,  the  walls  are  thrown  into  transverse  and  longitudinal  folds. 
The  OS  externum  is  usually  torn,  especially  upon  the  sides,  and  the 
thickened  labia  roll  outward.  The  length  of  the  canal  measures  tAvo 
and  three  quarters  inches  and  upward.  At  the  end  of  twelve  hours 
the  distinction  between  the  cervix  and  vagina  is  clearly  marked,  and 
the  OS  internum  is  so  far  closed  that  a  certain  amount  of  force  is 
requisite  to  pass  two  fingers  into  the  uterine  cavity.  The  contraction 
of  the  OS  internum  renders  the  longitudinal  folds  more  pronounced  in 
the  upper  portion  of  the  canal.  From  this  time  on,  the  involution  of 
the  cervix  advances  rapidly.  At  the  end  of  twelve  days  the  canal  is 
shortened  to  an  inch  in  length.  As  the  longitudinal  muscles  contract, 
the  plicas  palmat*  become  distinct  as  transverse  ridges.  The  longi- 
tudinal folds,  Avith  the  exception  of  the  anterior  and  posterior  ridge 
which  belong  to  the  plic«  palmate,  disappear  with  the  retrograde 
changes  which  take  place  in  the  mucous  membrane.  The  os  exter- 
num long  remains  patulous,  and  permits  the  finger  to  pass  to  the  os 
internum  for  a  period  varying  between  the  seventh  and  fourteenth 
days.  The  anterior  lip  is  thicker  than  the  posterior,  and  is  frequently 
the  seat  of  erosions  and  granulations.     The  involution  of  the  vaginal 

*  Leopold,  Studien  iiber  die  Uteriisschleimhaut.  etc..  Arch.  f.  Gynaek..  Bd.  xii. 
p.  169 ;  Engelmann,  The  Mucous  Membrane  of  the  Utenis,  Am.  Jour,  of  Obstel., 
May,  1875 ;  Spiegelberg.  Lehrbuch,  p.  214  ;  Schroeder.  Lehrbuch,  p.  232  ;  Ktsx- 
NER,  Die  Losung  der  miitterlichen  Eihiiute,  etc.,  Arch.  f.  Gynaek..  Bd.  xiii,  p.  422  : 
PbiedlXndkr,  Arch.  f.  Gynaek.,  Bd.  ix,  p.  22. 


24-1:  THE   PUERPERAL   STATE. 

portion  is   not  completed   until   after   the  expiration  of    five   to    six 
weeks.* 

The  Vagina. — The  vagina  during  the  tlrst  few  days  is  soft,  smooth, 
and  relaxed,  and  requires  from  three  to  four  weeks  to  regain  its  nor- 
mal dimensions.  The  contraction  and  involution  proceed  more  rap- 
idly at  the  introitus  than  above  in  the  neighborhood  of  the  fornix, 
though,  owing  to  the  presence  of  lacerations,  it  remains,  with  few 
exceptions,  permanently  wider  than  in  women  who  have  never  borne 
children. 

Position  of  the  Uterus.— Immediately  after  the  expulsion  of  the 
placenta  the  contracted  uterus  is  felt  through  the  abdominal  walls  as  a 
tirm,  solid  body,  of  a  flattened,  pyriform  shape.  When  both  hips  are 
on  the  same  level,  and  both  bladder  and  rectum  are  empty,  the  uterus 
is  found  in  the  median  line  with  the  fundus  between  the  symphysis 
and  the  navel.  At  the  same  time  the  Aveight  of  the  body  and  the 
laxity  of  the  abdominal  walls  lead  to  a  moderate  degree  of  anteflex- 
ion. Urine  in  the  bladder  and  fa»ces  in  the  rectum  give  rise  to  a  cer- 
tain amount  of  lateral  displacement,  and  now  and  then  to  a  torsion 
of  the  uterus  upon  its  long  axis.  As  in  pregnancy,  the  fundus  of  the 
uterus  is  thus  generally,  though  not  always,  directed  to  the  right, 
and  the  left  border  looks  to  the  front.  The  mean  elevation  of  the 
fundus  above  the  symphysis  is  about  four  and  one  third  inches,  the 
width  of  the  fundus  is  upward  of  four  and  a  half  inches,  and  the 
length  of  the  entire  uterine  cavity,  as  measured  by  the  sound,  is  in 
the  neighborhood  of  six  inches.  The  dimensions  of  the  uterus  are 
somewhat  less  in  primiparae  than  in  multiparae.  A  full  bladder  pushes 
the  fundus  upward,  and  increases  the  longitudinal  diameter  of  the 
organ.  Borner  has  observed  an  increase  from  this  cause  amounting 
to  three  and  a  half  inches. 

A  diminution  in  the  size  of  the  uterus  is  apparent  in  most  cases  in 
the  course  of  the  first  twenty-four  hours.  An  actual  increase  is  either 
pathological,  or  due  to  the  above-mentioned  influence  of  the  bladder. 
The  diminution  is  most  marked  in  the  first  twenty  days,  but  afterward 
progresses  at  a  slow  rate.  About  tht  tenth  day  the  fundus  sinks  below 
the  level  of  the  symphysis  pubis,  and  the  posterior  surface  of  the  ante- 
fleeted  uterus  occupies  the  plane  of  the  brim.f 

After-Pains. — The  reduction  of  the  uterus  in  the  first  few  days  of 

*  LoTT,  Zur  Anatomie  und  Physiologie  der  Cervix  Uteri,  pp.  87  ei  seq.  BOrner, 
Ueber  den  puerperalen  Uterus,  p.  47,  states  that  at  the  end  of  the  second  week  the 
OS  internum  permits  the  passage  of  the  finger  in  about  half  the  cases,  but  is  closed 
in  all  by  the  end  of  the  third  week. 

f  BoRNER,  loc,  cit. ;  Crede,  Beitrage  zur  Bestimmung  der  normalen  Lage  der 
gesunden  Gebarmutter,  Arch.  f.  Gynaek.,  Bd.  i,  1870,  p.  84;  Pfannkuch.  Ueber  die 
Eyifluss  der  Nachbar-Organe  auf  die  Lage  und  Involution  der  puerperalen  Uterus, 
Arch.  f.  Gynaek.,  Bd.  iii,  1872,  p.  327. 


I 


THE   PHYSIOLOGY  AND   MANAGEMENT   OF   (  IlllJ)i;i;i).      245 

tlie  childbed  period  is  in  the  main  the  result  of  contractions,  termed 
after-pains,  resembling  those  of  labor  both  as  regards  the  hardenino-  of 
the  uterine  walls  perceptible  through  the  abdominal  coverings,  and  the 
nature  of  the  dolorous  sensations  which  they  evoke.  The  after-pains 
stretch  over  a  period  varying  from  one  to  four  days.  Their  duration 
and  intensity  are  in  inverse  proportion  to  the  duration  and  activity  of 
the  preceding  labor.  On  this  account  they  are  more  pronounced  in 
multiparas,  while  they  are  often  absent  subsequent  to  a  first  delivery. 
They  are  intimately  associated  with  the  permanent  retraction  of  the 
uterus,  and  are  therefore  to  be  regarded  as  a  normal  and  favorable 
phenomenon.  T'hey  are  especially  prominent  in  cases  of  overdisten- 
tion  of  the  uterus,  as,  for  instance,  in  cases  of  twin  pregnancies  and 
hydramnios.  Suckling  the  infant  produces  reflex  contractions  of  a 
somewhat  intense  character. 

The  Lochia. — 'I'he  discharges  from  the  genital  passage  consequent 
upon  delivery  are  termed  the  lochia.  At  first  the  latter  are  composed 
of  pure  blood  with  coagula  of  fibrin,  but  after  a  few  hours  the  wounded 
surface  of  the  uterus  furnishes  an  abundant  exudation  of  a  serous,  alka- 
line fluid,  which  washes  away  in  its  descent  the  secretion  from  the  cer- 
vix and  the  vaginal  mucus.  For  the  first  two  or  three  days  the  lochia 
are  of  a  red  color  {lochia  ri(brn)  from  the  commingling  of  blood,  while 
upon  the  third,  fourth,  and  sometimes  upon  the  fifth  day,  as  the  san- 
guineous elements  diminish,  they  present  a  pale-red  color  (lochia  serosa). 
As  constituents,  we  find  under  the  microscojie  cervical  and  vaginal  epi- 
thelium, blood  and  mucus  corpuscles,  bits  of  decidua,  and  sometimes 
shreds  of  membranes  and  of  the  placenta.  The  organic  constituents 
consist  of  albumen,  mucine,  the  saponified  fats,  and  a  variety  of  saline 
matters.  From  the  fifth  to  the  seventh  or  eighth  day  the  discharge 
continues  thin,  but  the  blood-corj)uscles  become  less  abundant,  while 
there  is  an  increase  in  leucocytes  and  fatty  globules.  In  the  second  week 
the  discharge  becomes  of  a  grayish- white  or  greenish-3^ellow  color  (lochia 
alba  sen  lactia),  and  of  a  creamy  consistence.  It  contains  chiefly  leu- 
cocytes, young  epithelial  cells,  spindle-shaped  connective-tissue  cells, 
fat-granules,  free  fat,  and  crystals  of  cholesterine.  The  reaction  is 
neutral  or  acid.  Gradually  the  discharge  diminishes,  becomes  trans- 
parent, and  finally  assumes  a  normal  appearance.  The  vaginal  lochia 
in  the  rule  are  found  to  contain  a  variety  of  micro-organisms,  such  as 
the  diplo-  and  strepto-cocci,  rod  bacteria,  the  trichomonas  vaginalis,  and 
sometimes  gonococci.  They  vary  greatly  in  quantity,  and  increase  in 
abundance  with  the  advance  of  the  puerperal  week.  They  are  derived 
in  part  from  germs  present  in  the  vagina  previous  to  confinement,  and 
in  part  obtain  entrance  through  the  vulva.  In  the  vagina  the  condi- 
tions for  their  development  are  peculiarly  favorable.  The  number  can 
be  greatly  limited  by  hygienic  measures.  When  they  obtain  access  to 
the  uterine  cavity  their  power  for  evil  is  grciitly  .-uigmontod.     Toward 


246 


THE    rUKUPHKAL   STATE. 


the  end  of  the  first  week,  and,  espeeiall}'  after  leaving  the  bed,  fresh 
blood  often  makes  its  appearance.* 

The  quantity  of  the  lochia  varies  with  the  peculiai'ities  of  the  indi- 
vidual. It  is,  as  a  rule,  greater  in  nuiltipar;v,  in  women  who  do  not 
uurse  their  children,  and  in  those  of  flabby  fiber,  who  habitually  men- 
struate abundantly.  The  mean  quantity,  according  to  Gassner,  of  the 
lochia  omenta  or  rubra  (to  fourth  day)  amounts  to  nearly  two  and  a 
fourth  pounds ;  of  the  lochia  serosa  (to  sixth  day)  to  rather  more  than 
nine  ounces;  and  of  the  lochia  alba  (to  ninth  day)  to  six  and  two  thirds 
ounces;  so  that  the  entire  amount  lost  during  the  first  eight  days 
reached  the  total  amount  of  nearly  three  and  a  quarter  pounds. 

The  Secretion  of  Milk. 

Anatomical  Considerations. — The  breasts,  which  furnish  the  secre- 
tion of  the  milk,  are  two  large  glands  of  the  compound  racemose  vari- 
ety.    They  are  covered  by  a  fine,  su]i]ile  skin  and  a  layer  of  adipose 


I 


Fig.  129.— Mammary  gland,  a.  nipple,  the  central  iwrtiou  of  which  is  retracted  :  b,  areola  : 
c,  c,  c,  c,  c  lobules  of  the  gland  ;  1,  sinus,  or  dilated  portion  of  one  of  the  lactiferous  ducts  ; 
A  extremities  of  the  lactiferous  ducts.    (.Liegeois.) 

tissue,  which  increases  in  thickness  toward  the  periphery  of  the  organ. 
The  mass  of  the  glandular  substance  is  composed  of  from  fifteen  to 

*  Fide  ScHBOEDER.  Lehrbuch,  etc.,  6te  Aufl..  p.  226;  Spikoklberg    LehrbTK'h 
p.  218. 


THE   PHYSIOLOGY  AND   MANAGEMENT   OF   CHILDBED.       -f^- 

twenty-four  lobes,  which  in  turn  are  subdivided  into  lobules  made  u]) 
of  a  greater  or  less  number  of  acini,  or  culs-de-sac.  Fine  canaliculi 
start  from  the  latter,  and  unite  together  to  form  the  canals  of  the 
lobules.  These  again  anastomose,  to  form  a  principal  canal  for  eacli 
lobe,  termed  the  lactiferous  ducL  The  lactiferous  ducts  terminate  at 
the  nipple  by  small  openings  measuring  only  from  one  sixtieth  to  one 
fortieth  of  an  inch.  Each  duct,  as  it  passes  downward,  enlarges  in  the 
nipple  to  one  twenty-fifth  or  one  twelfth  of  an  inch  in  diameter,  aud 
beneath  the  areola  it  presents  an  elongated  dilatation,  from  one  sixth 
to  one  third  of  an  inch  in  diameter,  called  the  sinus  of  the  duct 
(Flint).  The  spaces  between  the  lobes  are  filled  with  adipose  tissue, 
and  the  various  elements  which  constitute  the  mammary  glands  are 
united  into  a  single  mass  by  a  dense  connective  tissue  continuous  with 
that  of  the  subcutaneous  layer.  The  acini,  which  are  merely  rudiment- 
ary in  the  non-pregnant  state,  are  lined  with  a  single  layer  of  small 
polyhedral  cells,  assuming  a  more  cylindrical  character  in  the  neighbor- 
hood of  the  canalicular  ducts.  The  main  ducts  are  lined  with  low 
cylindrical  cells,  and  contain  m  their  walls  non-striated  muscular  fibers, 
the  contractions  of  which  are  the  cause  of  the  spurting  of  the  milk  in 
lactation. 

During  pregnancy  the  breasts  enlarge  m  consequence  of  the  swell- 
ing and  increase  of  the  connective  tissue,  the  accumulation  of  fat 
between  the  lobes,  and  the  multiplication  of  the  acini,  which  fill  with 
fatty  globules  resulting  from  the  disintegration  of  the  lining  epithelial 
cells.  The  changes  in  the  secretory  apparatus  give  rise  to  irregularly 
distributed  nodular  cords,  which,  however,  at  first  are  most  distinct 
at  the  periphery,  and  thence  advance  toward  the  center  of  the  organ. 
With  continued  development  a  lactescent  fluid  is  produced,  which 
either  exudes  spontaneously  from  the  nipple  or  is  discharged  by 
pressure. 

Milk-Fever. — About  the  third  or  fourth  day  of  the  childbed  period 
the  turgescence  of  the  breasts  is  suddenly  increased,  and  they  become 
full,  tense,  nodular,  and  sensitive  to  the  touch.  The  axillary  glands 
enlarge,  and  radiating  pains  are  experienced  in  the  arm  and  shoulder. 
The  intensity  of  the  mammary  congestion  varies  in  differejit  individ- 
uals. It  is  more  pronounced  in  women  who  postpone  nursing  their 
children  until  after  the  secretion  of  milk  is  fully  established.  In  ex- 
ceptional cases  it  may  be  absent  altogether.  Since  the  general  intro- 
duction of  the  thermometer  into  practice,  and  the  better  understanding 
of  the  causes  of  febrile  temperatures  in  the  puerperal  state,  the  exist- 
ence of  a  distinct  milk-fever  referable  to  functional  disturbances  in 
the  breasts  during  the  period  in  question  has  been  found  to  be  an  en- 
tirely exceptional  occurrence.  The  temperature  tables  which  have 
been  kept  with  great  regularity  for  the  past  ten  years  in  the  Maternity 
Hospital  of  this  city  prove  that,  under  normal  conditipns,  the  tempera- 


248 


THE   PUERPERAL  STATE. 


tares  of  tlio  third  day  do  not  rise  above  100^°.  With  tliis  sub-febrile 
increase  there  is,  indeed,  often  conjoined  considerable  general  dis- 
turbance, indicated  by  slight  chilly  sensations,  headache,  anorexia, 
and  a  quickened  pulse,  which,  however,  disappear  in  the  course  of 
twenty-four  hours,  with  profuse  perspiration,  and  an  abundant  secre- 
tion of  milk.  Most  writers  regard  the  higher  temperatures  which  are 
sometimes  found  associated  with  extreme  turgescence,  tenderness,  and 


Fifi.  180.-  Section  tliroujili  iiL-iiiiis  from  breast  of  a  nursing  woman.     iBiUroth.) 


reddening  of  the  mammae,  and  which  subside  when  the  latter  are 
partially  unloaded,  as  dependent  upon  a  non-suppurative  form  of 
parenchymatous  inflammation. 

Composition  of  Milk. — Milk  is  composed  of  a  fluid  portion  and  of 
formed  constituents,  the  first  derived  from  the  blood,  and  the  second, 
termed  the  milk-globules,  from  the  epithelial  contents  of  the  acini. 
In  the  production  of  the  milk-globules  the  gland-cells  actively  mul- 
tiply^ and  become  filled  with  granular  particles,  which  gradually  co- 
alesce to  form  drops  of  fat.  Subsequently  the  nuclei  and  the  contours 
of  the  cells  disappear,  so  that  the  latter  consist  of  mulberry-shaped 
aggregations  of  fat-drops  held  together  by  the  remains  of  the  cell-pro- 
toplasm. The  epithelial  elements  thus  metamorphosed  are  termed 
colostrum-corpuscles.  They  are  found  sparingly  distributed  in  the 
crude,  imperfectly  formed  secretion  known  as  colostrum,  which  is  fur- 
nished by  the  breasts  of  women  who  have  been  but  recently  confined. 
Finally,  the  fat-globules  of  large  and  small  size  separate  from  one 
another,  and  form  an  emulsion  with  the  fluid  transuded  from  the 
blood,  a  process  aided,  according  to  Kehrer,  by  the  diffusion  through 
the  fluid  of  the  residual  protoplasm  of  the  cells.* 

*  Kehrer.  Zur  Morphologie  des  Milch-Caseins,  Arch.  f.  Gynaek.,  Bd.  ii,  p.  1. 


THE   PHYSIOLOGY  AND   MANAGEMENT  OP  CHILDBED.       v^i) 

Colostrum  is  a  watery,  semi-opaque,  mueiliagiuous  fluid,  containing' 
yellowish  streaks  composed  of  fat-globules  and  fatty-degenerated  cells 
which  hang  together  in  stringy  masses.  It  is  distinguished  from  true 
milk  not  only  in  the  physical  characteristics  mentioned,  but  in  the 
greater  proportion  of  sugar  and  inorganic  salts  it  contains,  and  in  the 
.  fact  that  it  coagulates  upon  boiling.  It  possesses  laxative  qualities, 
wliich  render  it  of  use  to  the  infant  in  aiding  the  removal  of  the  me- 
conium. 

Perfectly  formed  milk  contains  from  2-5  per  cent  to  7-6  per  cent 
butter  in  emulsion,  and  from  3-2  per  cent  to  six  per  cent  milk-sugar 
in  solution.  Both  of  these  substances  are  directly  manufactured  by 
the  gland-structures.  It  possesses  likewise  a  protein  substance  termed 
casein,  which  fluctuates  in  quantity  between  one,  three,  and  four  per 
cent.  Kehrer  maintains  that  it  is  not  held  in  the  milk  in  solution, 
but  is  composed  of  particles  derived  from  cell-protoplasm  which  are 
diffused  through  the  fluid.  The  salts  in  the  milk  amount  to  0*14  per 
cent.* 

The  Diagnosis  of  the  Puerperal  State. — The  diagnosis  of  recent  de- 
livery is  based  upon  the  physiological  conditions  which,  we  have  seen, 
characterize  the  puerperal  state.  Thus,  the  abdomen  is  flabby  and 
wrinkled,  with  pigmented  linea  alba,  and  is  traversed  by  white  and  red 
lines ;  the  breasts  are  full,  tense,  and  nodular,  and  secrete  milk  or 
colostrum  ;  the  areola  about  the  nipple  is  discolored ;  the  uterus  is 
enlarged,  anteflexed,  palpable  through  the  abdominal  wall,  and  is  ex- 
cited to  contract  by  pressure  ;  the  vulva  is  swollen,  the  labia  gape 
apart,  the  hymen  is  ragged,  the  perineum  is  distensible,  and  in  recent 
cases  lacerations,  in  older  ones  ulcers  or  granulating  wounds,  are  found 
about  the  vaginal  orifice ;  in  the  smooth,  lax  vagina  there  is  observable 
the  absence  of  the  columns  rugarum ;  the  cervix  is  soft,  wide  below 
and  narrowing  above,  with  the  labia  often  torn  and  contused  ;  when 
the  finger  can  be  passed  into  the  uterine  cavity,  thrombi  may  be 
felt  at  the  placental  site;  finally,  the  lochia  are  hardly  likely  to 
be  confounded  with  haemorrhages  or  discharges  from  non-puerperal 
causes. 

During  the  first  two  weeks  an  approximative  estimate  may  be  made 
as  to  the  date  of  confinement  by  bearing  in  mind  that  just  after  de- 
livery colostrum  is  found  in  the  breasts,  the  lochia  are  bloody,  and  the 
lacerations  about  the  vulva  present  a  fresh  appearance ;  that  during 
the  following  days  the  lochial  secretion  changes  first  to  a  serous  and 
then  to  a  purulent  character ;  that  the  uterus  gradually  diminishes  in 
size,  the  fundus  at  the  tenth  day  sinking  below  the  upper  border  of  the 
symphysis,  while  the  os  internum  remains  patulous  to  the  tenth  day, 
and  is  usually  impassable  for  the  finger  after  the  twelfth  day. 
*  Spiegelberg,  loc.  cit.,  p.  221. 


250 


THE   PUERPERAL   STATE. 


The  Xew-borx  Ixfant. 


With  the  first  inspiration  the  thorax  exjiands  and  air  fills  the 
alveoli  of  the  lungs  ;  at  the  same  time  the  blood  passes  from  the  right 
side  of  the  heart  to  the  capillaries  of  the  pulmonary  organs,  and  is 
returned  arterialized  to  the  left  side  of  the  heart.  As  a  consequence 
of  the  establishment  of  the  pulmonary  circulation,  the  ductus  arteri- 
osus contracts,  the  foramen  ovale  closes,  and  the  left  ventricle  under- 
goes eccentric  hypertrophy.  With  the  diversion  of  a  part  of  the  blood- 
currents  to  the  lungs,  the  pressure  in  the  aorta  sinks,  and  the  circula- 
tion in  that  portion  of  the  umbilical  arteries  which  lies  outside  the 
navel  ceases,  while  thoracic  aspiration  empties  the  umbilical  vein.  The 
cord  dries  from  the  cut  surface  toward  the  navel,  and  drops  off  on  the 
fourth  or  fifth  day.  The  line  of  demarkation  forms  at  the  termina- 
tion of  a  capillary  network  which  extends  upward  upon  the  cord  to  a 
distance  of  from  three  to  four  lines  from  the  skin.  When  the  cord 
drops  off,  a  wounded  surface  is  left,  which  heals  in  a  few  days. 

The  swelling  upon  the  presenting  part  subsides  mostly  in  twenty- 
four  to  forty-eight  hours.  The  head  slowly  resumes  its  normal  shape 
— a  process  completed,  probably,  in  the  course  of  two  to  thi-ee  weeks. 

Soon  after  birth  the  meconium  is  discharged  from  the  intestines, 
and  in  a  few  days  the  evacuations  assume  a  feculent  character.  The 
production  of  pepsin  in  the  stomach,  and  the  secretion  by  the  pancreas 
of  a  fluid  capable  of  emulsifying  fats  and  digesting  albuminoid  sub- 
stances, render  the  assimilation  of  milk  practicable.  The  kidneys 
excrete  an  abundance  of  urine  of  a  low  specific  gravity. 

About  the  third  day  an  exfoliation  of  the  epithelium  begins,  which 
is  maintained  for  a  week,  or  even  a  longer  period.  During  this  time 
the  hyperaemia  of  the  skin  is  very  marked,  and  imparts  to  it  a  red 
color,  which  as  it  fades  passes  into  a  yellowish  tint.  The  breasts  in 
both  sexes  swell  very  commonly,  become  red  and  sensitive,  and  yield 
upon  pressure  a  serous,  milky  fluid. 

Icterus  of  the  new-born  infant  is  a  pretty  common  affection.  Its 
occurrence  is,  however,  largely  influenced  by  local  conditions.  Thus, 
Porak  placed  the  frequency  at  eighty  per  cent  among  the  children 
born  in  the  Hopital  Cochin  in  Paris ;  Kehrer,  in  the  vast  maternities 
of  Vienna,  at  sixty-eight  per  cent ;  Ebstein,  in  Prague,  at  forty-two 
per  cent ;  while  West  declares  it  is  a  rare  phenomenon  at  the  Rotunda 
Hospital  in  Dublin.  It  develops  usually  upon  the  second  or  third 
day,  and  ends,  as  a  rule,  by  the  sixth  to  eighth  day.  Kehrer  *  has 
shown  statistically  that  it  occurs  more  frequently  in  boys,  in  prema- 
ture mfants,  in  the  children  of  primiparae,  and  as  a  consequence  of 
malpresentations.     It  is  likewise  promoted  by  atelectasis,  by  intestinal 

*  Kehrer,  Studien  iiber  den  Icterus  Neonatorum,  Jahrbuch  f.  Paediatrik,  Bd. 
ii,  p.  71,  1871. 


THE   PHYSlULOGV   AND   MANAGEJMKNT   OF   CHILDBED.      251 

affections,  bv  depressing  the  temperature  of  the  child,  by  insufficient 
feeding,  and,  in  a  word,  by  all  the  various  patliological  conditions  and 
unfavorable  hygienic  influences  intensifying  or  giving  an  abnormal 
direction  to  the  ordinary  changes  which  take  place  in  the  blood  (Eb- 
stein).  Its  frequency  in  lying-in  hospitals  is  probablv  connected  with 
a  septic  infection,  for  which  the  wounded  surface  at  the  navel  furnishes 
the  point  of  entry.  It  is  rarely  dependent  upon  gastro-duodenal  ca- 
tarrh, npon  a  narrowing  of  the  bile-duct,  or  upon  retention  of  meconi- 
um. The  ffeces  are  stained  with  bile.  In  all  the  tissues  of  the  body, 
and  most  abundantly  in  the  kidneys,  pigment-crystals  and  yellowish- 
red  amorphous  granules  are  fonnd  deposited  in  greater  or  less  quanti- 
ties. It  is  as  yet  an  unsettled  question  as  to  Avhether  these  pigment- 
bodies  are  the  products  of  the  liver  or  result  from  the  disintegration  of 
the  blood-corpuscles.  A  very  considerable  destruction  of  the  latter  is 
found  in  all  cases  of  icterus  of  the  new-born.  The  tissue-waste  is  like- 
wise marked.  Hofmeier  *  found  the  average  loss  of  weight  in  icteric 
children  on  the  third  day  after  birth  was  9-3  per  cent  of  the  original 
weight,  whereas  in  non-icteric  children  it  was  but  5-69  per  cent.  The 
urine  contained  an  excess  of  nrea  and  uric  acid,  and  pigment-bodies 
proportioned  to  the  intensity  of  the  icterus.  The  pigment-bodies,  he 
claims,  'nirnished  the  characteristic  color  reaction  with  nitric  acid  of 
the  acids  of  the  bile.  An  expectant  treatment  is  the  only  rational  one. 
Laxatives  are  unnecessary,  and  perhaps  harmful. f 

Owing  to  the  discharge  of  meconium  and  urine,  and  the  limited 
amount  of  sustenance  at  its  disposal,  the  new-born  infant  experiences 
a  loss  of  weight  in  the  first  two  or  three  days,  estimated  at  from  seven 
to  eight  ounces.  After  the  second  or  third  day  the  loss  is  gradually 
i-eeovered,  so  that  between  the  fifth  and  eighth  days  the  weight  at  birth 
is  reached.  The  loss  of  weight  is  greater  in  the  children  of  primipara? 
than  in  those  of  multipara?,  in  artificially  nourished  infants,  and  where 
the  immediate  application  of  the  ligature  to  the  cord  at  birth  has  been 
resorted  to. 

The  Maxagemext  of  the  Puerperal  State. 

Sleep.— After  every  precaution  has  been  taken  against  haemorrhage, 
after  the  i):itient  has  been  washed  carefully  and  i)laced  upon  clean,  dry 
l)edding,  and  after  the  baby  has  been  bathed  and  dressed,  it  is  very  de- 
sirable that  the  mother  should  enjoy  a  few  hours  of  refreshing  sleep. 
To  this  end  the  room  should  be  darkened  and  absolute  stillness  en- 
forced. The  crying  of  the  baby,  the  affectionate  salutation  of  friends, 
or  the  tidying  of  the  room  by  household  Marthas,  often  becomes  the 

*  Hofmeier,  Die  Gelbsucht  der  neugeborencn,  Ztschr.  fiir  Geburtsli.  iiml  Gyiiaek., 
vol.  vii,  p.  287. 

t  Ebstein,  Ueber  die  Gelbsucht  bei  neugeboiviu'ii  Kiiuloni.  Volkiiiiiiurs  Sanunl. 
klin.  Vortr.,  No.  180. 


252 


THE  PUERPERAL  STATE. 


starting-point  of  nervous  restlessness,  which  is  with  difficulty  over- 
come  by  the  aid  of  the  strongest  soporifics.  Should  the  mother 
feel  faint  and  exhausted,  she  should  be  allowed  a  cup  of  hot  tea  or 
bouillon. 

In  multipara  it  is  well  to  leave  with  the  nurse  some  form  of  ano- 
dyne, to  be  administered  in  case  sleep  is  interrupted  by  the  frequent 
recurrence  and  severity  of  the  after-pains.  Opiates,  while  they  lull 
the  pain,  do  not,  after  labor,  arrest  those  physiological  changes  in  the 
uterus  with  which  the  after-pains  are  associated. 

Passing  Urine. — As  the  natural  impulse  to  urinate  after  delivery  is 
very  feeble,  even  when  the  bladder  is  full,  the  nurse  should  be  instructed 
to  solicit  the  patient  to  pass  water  in  the  course  of  eight  or  ten  hours. 
It  is  usually  recommended  that  the  act  of  urination  should  be  performed 
upon  the  back,  which,  of  course,  necessitates  the  use  of  the  bed-pan. 
It  has  been  my  own  rule  to  enforce  the  dorsal  position  during  the  first 
days  of  childbed,  but  there  are  a  good  many  women  who  are  able  to 
pass  water  without  difficulty  in  the  sitting  posture,  who  fail  in  the 
attempt. when  recumbent.  Goodell  therefore  advocates  the  practice  of 
raising  the  woman  for  purposes  of  urination  from  the  beginning  of 
childbed.  He  believes  that  the  occasional  assumption  of  the  ujjright 
attitude  for  a  brief  period  possesses  the  advantage  of  promoting  drain- 
age of  the  parturient  canal,  and  of  forestalling  the  evils  incident  to 
lochial  stagnation  in  the  vagina.  The  belief  tliat  such  a  course  in- 
creases the  risk  of  haemorrhage  he  regards  as  unfounded.  The  physician 
should  make  it  a  rule  to  visit  his  patient  within  twelve  hours  from  the 
time  of  confinement.  He  should  then  inquire  not  only  whether  she 
lias  passed  water,  but  ascertain  the  quantity  voided.  If  the  quantity 
has  not  exceeded  three  to  four  ounces,  he  should  introduce  the  catheter 
and  make  sure  that  the  bladder  is  completely  emptied.  In  cases  of  re- 
tention, the  urine  should  be  drawn  at  least  four  times  in  the  twenty- 
four  hours.  Before  using  the  catheter,  the  lochia  should  be  carefully 
washed  from  the  external  parts  with  a  warm  carbolized  fluid  (two  per 
cent),  as  the  lochial  discharge  after  the  first  day  is  liable  to  excite 
cystitis.  Both  the  catheter  and  the  operator's  hand  should  be  surgi- 
cally clean.  In  passing  the  catheter  beneath  the  bedclothes,  the  ure- 
thral orifice  can  readily  be  detected  by  first  feeling  for  the  tumefied 
urethra  with  the  index-finger  of  the  right  hand  through  the  anterior 
vaginal  wall,  and  then  following  it  in  a  forward  direction  until  the 
meatus  is  reached. 

Visits  of  the  Physician. — The  physician  should  see  his  patient  at 
least  once  daily  during  the  first  week  following  confinement.  During 
the  first  four  days  it  is  my  custom  to  make  both  a  morning  and  evening 
visit,  not  only  for  the  purpose  of  noting  carefully  the  pulse  and  tem- 
perature, but  to  be  sure  that  my  patient  is  not  made  a  victim  to  ti-adi- 
tional  prejudices  and  siiperstitions.      If  tlie  physician  will  take  the 


THE   PHYSIOLOGY   AND   MANAGEMENT  OF  CHILDBED.      253 

trouble  to  call  occasionally  upon  his  patient  subsequent  to  the  first 
week,  to  insure  the  unretarded  progress  of  puerperal  convalescence,  he 
will  do  much  to  circumscribe  the  field  of  gynaecological  practice. 

General  Directions. — Great  care  should  be  taken  to  keep  the  air  of 
the  lying-in  chamber  fresh  and  pure.  If  the  room  is  warm,  the  patient 
sliould  be  lightly  covered,  owing  to  the  tendency  during  childbed  to 
profuse  perspirations.  There  is  no  foundation  for  the  prevalent  belief 
that  it  is  dangerous  to  comb  the  hair  of  a  puerperal  woman.  Nothing 
contributes  so  much  to  the  removal  of  soreness,  and  the  healing  of 
wounds  in  the  genital  canal,  as  cleanliness. 

Where  the  antiseptic  pad  is  employed  this  object  is  attained  by 
thoroughly  washing  the  external  parts  with  a  bichloride  (1 : 5,000)  or  a 
carbolic  solution  (two  per  cent),  whenever  it  becomes  necessary  to 
change  the  pad  either  by  reason  of  the  evacuation  of  the  bowels  or 
bladder,  or  because  of  the  saturation  of  the  pad  with  the  lochial  dis- 
charge. From  the  latter  cause  alone  a  change  once  in  four  hours  in 
the  early  childbed  period  is  to  be  advocated.  The  pad  removed  should 
be  destroyed. 

When  the  ordinary  napkin  is  used  external  ablutions  should  be  em- 
ployed several  times  daily.  It  is  a  question  whether  the  present  tend- 
ency to  prohibit  the  vaginal  douche  is  warranted.  Against  its  employ- 
ment it  may  be  urged,  that  in  spite  of  the  addition  of  carbolic  acid  or 
corrosive  sublimate  there  is  statistical  evidence  that  the  vaginal  douche 
augments  the  chances  of  infection.  In  hospital  practice  it  has  invariably 
increased  the  morbidity  and  mortality  rate.  In  my  own  private  prac- 
tice, on  the  other  hand,  it  has  proved  to  many  patients  a  source  of 
comfort.  When  carefully  administered  by  nurses  trained  to  aseptic 
work  it  has  given  rise  to  no  injurious  symptoms,  and  I  still  occa- 
sionally employ  it — not,  however,  as  a  prophylactic,  but  because  of 
the  property  possessed  by  hot  vaginal  injections  to  assuage  pelvic  dis- 
comfort. ^^.^ 

Diet— The  diet  should  be  selected  with  reference  to  the  physio- 
logical requirements  of  the  patient.  Thus,  during  the  first  three  days, 
when,  as  a  rule,  the  patient  is  thirsty  and  is  indifferent  to  solid  food, 
the  diet  should  consist  of  gruel,  milk,  milk-toast,  and  tea ;  to  which 
may  be  added  clear  soups  and  bouillon,  and  soft-boiled  eggs,  should 
more  stimulating  aliments  be  called  for.  It  is  equally  desirable,  on  the 
one  hand,  to  avoid  exciting  colics  and  catarrhal  affections  of  the  stomach 
by  too  early  resorting  to  a  substantial  regimen,  and,  on  the  other,  to 
remember  that  the  speedy  establishment  of  an  abundant  milk  secretion 
is  apt  to  be  hindered  by  subjecting  women  to  a  process  of  semi-starva- 
tion. After  the  bowels  have  moved  on  the  third  or  fourth  day,  the 
normal  appetite  usually  returns.  All  easily  digested  articles  of  food, 
such  as  eggs,  chicken-broth,  small  birds,  steak,  chops,  and  the  like, 
according  to  the  taste  of  the  patient,  should  then  be  allowed.     Cooked 


254  THE   PUERPERAL  STATE. 

fruits  are  of  service  in  overcoming  the  natural  constipation  of  the 
puerperal  period.  The  popular  prejudice  against  fish  and  vegetables 
containing  a  large  amount  of  nitrogenized  substances  seems  to  me  well 
founded. 

Laxatives. — The  canonical  practice  of  administering  a  laxative  on 
the  third  day  is  of  unquestionable  utility.  In  most  women  there 
occurs  an  accumulation  of  fecal  matter  during  the  last  weeks  of  preg- 
nancy— an  accumulation  which  is  often  enormous  in  quantity,  and 
which  creates  a  predisposition  to  puerperal  affections.  The  remedies 
selected  should,  however,  be  adapted  to  the  peculiarities  of  the  individual. 
In  some  women  an  ordinary  injection  of  soap  and  olive-oil  in  water 
suffices  to  procure  an  adequate  evacuation  ;  in  others,  the  object  is  ful- 
filled by  the  milder  laxatives,  such  as  the  compound  rhubarb  pill,  a 
claret-glass  of  Huuyadi-Janos  water,  or  the  compound  licorice  jjowder 
of  the  German  pharmacopoeia  ;  while  in  obstinate  cases  a  calomel  purge, 
or  some  such  combination  as  the  post-jjaritim  pill  of  the  late  Prof. 
Barker,*  will  be  found  requisite.  Castor  oil  I  give  only  in  cases  of 
severe  colic,  either  alone  or  combined  with  fifteen  drops  of  laudanum. 
In  hemorrhoids  complicating  puerj^eral  convalescence,  I  can  add  my 
testimony  to  that  already  given  by  Prof.  Barker  as  to  the  specific 
curative  effect  of  half-grain  doses  of  aloes  administered  night  and 
morning. 

Nursing. — Every  healthy  woman  should  nurse  her  child  at  least 
through  the  puerperal  period.f  The  advisability  of  continuing  lacta- 
tion subsequent  to  the  resumption  of  household  duties  must  depend 
upon  the  question  as  to  whether  the  mother  is  in  a  position  to  make 
the  necessary  sacrifices  to  the  interests  of  the  child.  When  the  do- 
mestic and  social  demands  upon  her  time  and  thoughts  are  numerous 
and  pressing,  lactation  is  apt  to  be  imperfect,  and  the  child  will  not 
thrive.  Humanity,  in  such  cases,  requires  that  the  child  be  surren- 
dered to  a  wet-nurse.  Nursing  may  be  rendered  impossible  by  a  lack 
of  milk,  by  flattened,  misshapen  nipples,  and  by  the  health  of  the 
mother.  It  should  be  prohibited  in  phthisis,  in  epilepsy,  and  in  cases 
of  syphilis  contracted  shortly  before  the  birth  of  the  child. 

The  child  should  be  applied  to  the  breast  after  the  mother  has 
rested,  and  within  the  first  twelve  hours  following  the  end  of  labor. 
Soon  after  birth  the  child  seizes  the  nipple  eagerly,  and  though  the 
quantity  of  nourishment  obtained  is  small,  it  is  infinitely  better  adapted 
to  the  child's  needs  than  the  catnip-teas  and  sweet  oil  which  monthly 

*  Ext.  colocynth.  comp.,  3j ;  ext.  hyoscyami,  gr.  xv. ;  pulv.  aloes  soc,  gr.  x.; 
ext.  nuc.  vom.,  gr.  v. :  podophyllin,  ipecacuanha,  aa,  gr.  j.  M.  Ft.  pil.  (argent.)  No. 
xii.     Of  these,  two  usually  act  efficiently  and  without  causing  pain. 

t  The  quantity  of  milk  daily  consumed  by  the  infant  during  the  first  nine  days 
increases,  according  to  Deneke,  gradually  from  one  ounce  and  a  half  on  the  first 
day  to  about  fourteen  ounces  on  the  ninth  day.  Ueber  Ernahrung  des  Sauglings, 
Arch.  f.  Gynaek.,  vol.  xv,  p.  340. 


THE   PHYSIOLOGY  AND    MANAGEMENT   OF   CHILDBED.      9 


Z.)i> 


nurses  employ  as  substitutes.  The  early  apjolication  of  the  child  to 
the  breast  benefits  the  mother  by  promoting  the  contractions  and  the 
involution  of  the  uterus,  and  by  lessening  the  painful  distention  of  the 
breasts  which  occurs  at  the  time  when  the  function  of  lactation  is  fully 
established. 

As  the  child  sleeps  for  the  most  part  during  the  first  few  days  of 
existence,  no  rule  can  be  laid  down  with  regard  to  the  frequency  with 
which  it  should  be  placed  to  the  breast.  Afterward  it  should  be  ac- 
customed to  some  regular  routine.  So  long  as  the  stomach  is  of  small 
capacity  and  regurgitates  a  portion  of  its  food,  the  interval  should  not 
exceed  a  couple  of  hours.  From  an  early  period,  however,  the  child 
should  be  accustomed  to  sleep  six  hours  at  night,  which  gives  an  op- 
portunity for  the  mother  to  recuperate  her  strength.  This  discipline  is 
of  course  not  practicable  where  the  child  sleeps  in  the  same  bed  with 
the  mother.  After  six  months  the  child  should  not  nurse  oftener  than 
five  or  six  times  in  the  twenty-four  hours. 

The  breasts  should  be  suckled  in  alternation.  The  nipples  should 
be  carefully  washed  both  before  and  after  nursing.  The  addition  of 
boric  acid  to  the  water  prevents  the  development  of  fungi.  The  ex- 
treme sensitiveness  of  the  nipples  at  the  commencement  of  lactation 
can  be  greatly  relieved  by  applying  constantly  to  them  a  rag  wet  with 
the  liquor  plumM  subacetat.j  in  the  proportion  of  a  teaspoonful  to  a 
tumbler  of  water.  For  a  few  days  a  metallic  shield  over  the  nipples, 
to  prevent  the  rubbing  of  the  night-dress  or  the  bedclothes,  is  a  source 
of  comfort. 

Duration  of  Lying-in  Period. — Most  women  expect  permission  to  be 
given  them  to  sit  vip  ujjon  the  tenth  day.  There  should,  however,  be 
no  fixed  rule  about  leaving  the  bed  which  does  not  take  into  account 
the  individuality  of  the  specific  case.  Not  to  leave  the  bed  before  the 
tenth  day  is  a  safe  rule  in  normal  puerperal  convalescence ;  but,  where 
there  are  wounds  to  heal  by  granulation,  a  much  longer  period  of  time 
may  be  necessary.  Garrigues  *  expressed  his  conviction  that  "  the  up- 
right and  sitting  postures  ought  to  be  carefully  avoided  until  involu- 
tion has  proceeded  so  far  that  the  uterus  has  receded  from  the  anterior 
wall  of  the  abdomen  and  returned  to  the  pelvic  cavity  " — a  rule  which 
would  allow  one  woman  to  sit  up  in  a  week,  while  another  would  be 
kept  in  bed  two  weeks,  or  even  longer.  The  continuance  of  the  lochia 
rubra  should  serve  as  a  warning  against  a  change  to  the  upright  posi- 
tion. The  first  attempt  at  getting  up  should  be  tentative.  The  re- 
sumption of  household  duties  should  be  postponed  until  the  patient 
can  walk  about  without  fatigue  or  backache.  When  the  abdominal 
walls  are  greatly  relaxed,  a  well-fitted  bandage  should  be  worn  for 
weeks  subsequent  to  delivery. 

*  Garrigues,  Rest  after  Delivery,  Am.  Jour,  of  Obstet.,  October,  1880,  p.  861. 


256  THE   PUERPERAL  STATE. 

The  Cake  of  the  JS^ew-bokn  Infant. 

As  the  new-born  infant  possesses  feeble  powers  of  resistance  to 
cold,  the  first  bath  should  be  ninety-eight  degrees,  or  nearly  that  of 
the  body.  The  vernix  caseosa  should  be  softened  by  oil  or  fat-inunc- 
tion, and  gentleness  employed  in  its  removal.  The  child  should  then 
be  gently  dried  in  soft,  warm  cloths,  and  carefully  examined  with 
reference  to  any  possible  defect  of  formation  or  development.  The 
cord  should  be  wrapped  in  absorbent  cotton,*  and  held  in  place  upon 
the  left  side  by  a  flannel  bandage.  After  the  cord  has  separated,  the 
wounded  surface  should  be  dressed  with  iodoform,  or  bismuth  powder. f 
The  clothing  of  the  child  is  the  province  of  the  nurse,  and  varies  con- 
siderably in  the  different  social  ranks.  Cleanliness  and  fresh  air  are 
essential  to  healthy  development.  To  avoid  sprue,  the  mouth  of  the 
child  should  be  washed  with  cool  water  each  time  after  nursing. 

Selecting  a  Wet-Nurse.— Should  the  mother  be  unable  to  nurse  her 
child,  a  wet-nurse  should  be  urgently  recommended.  In  selecting  the 
latter,  an  examination  should  be  made  with  regard  to  her  constitution 
and  health.  The  physician  should,  by  inspecting  the  throat,  the  legs, 
the  glands  of  the  neck,  and,  if  possible,  the  genital  organs,  exclude 
the  existence  of  a  syphilitic  or  strumous  taint.  A  nurse  should  be 
between  twenty  and  thirty-five  years  of  age,  and  should  present  all  the 
appearances  of  good  health.  The  gums  should  be  red  and  firm  ;  the 
breasts  should  preferably  possess  a  pyriform  shape,  and  should  be  mar- 
bled with  blue  veins ;  it  is  not  necessary  that  they  should  be  large,  but 
they  should  be  firm,  elastic,  and  nodular  from  abundance  of  glandular 
structure ;  the  nipples  should  be  well  formed,  prominent,  and  free 
from  cracks  and  erosions ;  the  milk  should  flow  easily,  and  not  be  too 
bluish  in  color ;  the  age  of  the  milk  should  bear  some  correspoTidence 
to  that  of  the  child  to  be  suckled.  Aside  from  the  question  of  adapta- 
bility, it  is  obvious  that,  where  a  great  discrepancy  exists,  the  milk  of 
the  nurse  is  liable  to  fail  before  the  time  of  weaning  is  reached.  One 
of  the  best  tests  of  a  nurse's  capacity  is  the  appearance  of  her  own 
child.  If  the  latter  is  plump,  with  well-rounded  limbs,  and  with  a 
healthy  skin  and  mucous  membranes,  the  presumptions  are  in  her 

*  This  plan,  which  I  first  saw  recommended  by  Dr.  W.  D.  Babcock,  of  Evans- 
ville,  Indiana  (Am.  Jour,  of  Obstet.,  October,  1888,  p.  1055),  has  since  been  warmly- 
praised  by  Crede  and  Weber,  Arch.  f.  Gynaek.,  vol.  xxxiii,  p.  73. 

f  Dr.  Goodell  seizes  the  cord,  after  it  has  been  cut  as  usual,  between  the  thumb 
and  forefinger  of  the  left  hand,  near  the  navel,  and  then  strips  off  the  gelatin  of 
Wharton  with  the  thumb  and  forefinger  of  the  right  hand.  The  pressure  at  the 
navel  is  next  temporarily  suspended  where  the  internal  portions  of  the  vessels 
collapse.  The  cord  is  thereupon  subjected  to  a  second  stripping,  tied  in  the  usual 
manner,  and  left  free  without  any  dressing  whatever.  The  result  is  that  it  separates 
without  any  bad  smell.  ( Vide  Parry's  note,  Leishman's  Midwifery,  third  American 
edition,  p.  608.) 


THE  PHYSIOLOGY  AND  MANAGEMENT   OF   CHILDBED.      257 

favor,  even  if  she  does  not  present  in  her  own  person,  as  Jacobi  sport- 
ively suggests,  a  "combination  of  Aphrodite,  Athene,  and  Psyche." 
When  a  choice  has  once  been  made,  a  change  should  not  be  recom- 
mended without  a  fair  trial.  It  is  by  no  means  uncommon  for  a  nurse 
but  recently  separated  from  her  child,  placed  among  strangers,  and 
introduced  to  a  foreign  mode  of  life,  to  temporarily  puffer  from  a  dimi- 
nution of  the  lacteal  secretion,  the  milk  returning  in  a  brief  period 
under  the  influence  of  kindness,  habit,  and  a  nourishing  regimen. 
Moderate  exercise  is  necessary  for  the  maintenance  of  health.  The 
nurse  should  be  allow^ed  to  drink  milk  freely,  but  malt  liquors  should 
be  prohibited,  at  least  until  toward  the  close  of  lactation. 

Artificial  Feeding. — If  it  is  impossible  to  procure  the  services  of  a 
wet-nurse,  or  if  the  aversion  of  the  parents  to  wet-nurses  as  a  class 
proves  unconquerable,  artificial  alimentation  must  be  tried.  It  is  un- 
questionable that  many  babies  thrive  fairly  when  brought  up  on  the 
bottle.  For  success,  scrupulous  cleanliness,  punctuality,  intelligence, 
and  experience  are  requisite.  The  beautiful  roundness  of  outline,  the 
Men  aise,  and  the  easy  dentition  of  infants  at  the  breast  are,  however, 
rarely  attainable  by  those  who  are  brought  up  by  hand.  Bottle-fed 
infants  are  apt  to  be  lean,  to  be  subject  to  attacks  of  indigestion,  and 
to  suffer  from  nervous  disturbances  when  teething.  If  cow's  milk  is 
used  as  a  substitute  for  human  milk,  the  experiment  is  more  likely  to 
prove  a  success  in  the  country,  where  the  milk  can  be  obtained  fresh 
morning  and  evening,  than  in  the  city,  where  milk  is  of  necessity  at 
least  twelve  hours  old  at  the  time  of  delivery,  and  thirty-six  hours 
old  before  a  fresh  supply  can  be  obtained.  My  own  experience  inclines 
me  to  favor  employing,  where  it  is  practicable,  milk  from  one  cow, 
especially  if  the  cow  is  selected  with  reference  to  the  child's  individu- 
ality, precisely  in  the  same  manner  as  a  wet-nurse  would  be  selected. 
The  fitness  of  the  milk  to  the  child  is  to  be  determined  rather  by  ex- 
periment than  by  analysis.  In  a  general  way,  however,  it  is  well  to 
remember  that  the  milk  of  a  very  young  cow  is  deficient  in  fat-glob- 
ules, while  that  of  an  old  cow  is  apt  to  err  on  the  side  of  excessive 
richness,  and  that  either  extreme  is  equally  liable  to  tax  the  infantile 
organs  of  digestion. 

The  difference  in  the  digestibility  of  human  and  cow's  milk  is  de- 
pendent upon  a  difference  in  the  molecular  arrangement  of  the  casein 
varieties  they  respectively  contain.  The  acid  of  the  stomach  precipi- 
tates human  casein  in  the  form  of  flocculent  shreds,  while  that  of  the 
cow's  milk  is  converted  into  firm,  solid  masses.  Now,  of  the  two  forms 
it  has  been  experimentally  proved  that  the  former  is  much  more  solu- 
ble in  the  gastric  juice  than  the  latter.  With  many  physicians  the 
favorite  plan  for  neutralizing  this  objection  consists  in  substituting 
cream  for  milk  (diluted  at  first  with  three  and  afterward  with  two 
parts  water  [Biedert]),  and  thus  to  reduce  the  quantity  of  casein  to 
17 


258  THE  PUERPERAL  STATE. 

minimum  proportions;  but  this  diet,  by  confining  the  child  almost 
entirely  to  the  hydrocarbons,  to  the  exclusion  of  the  protein  constit- 
uents, has  never  seemed  to  me  in  practice,  even  when  well  borne,  to 
meet  the  full  tissue  requirements  of  a  growing  child.  After  many 
trials  of  this  mixture,  which  found  a  warm  advocate  in  the  late  Pro- 
fessor Childs,  of  this  city,  I  have  finally  returned  to  milk  of  good 
standard  quality,  stirring  it  before  using  to  distribute  the  fat-globules 
evenly  between  the  different  layers,  and  adding  to  it  water  propor- 
tioned to  the  age  of  the  child,  beginning  with  eight  tablespoonfuls  of 
milk  to  eight  of  water,  increasing  the  one  and  diminishing  the  other 
a  tablespoonful  at  a  time  as  rapidly  as  the  digestive  organs  exhibit  a 
toleration  of  the  change.  The  water  does  not,  of  course,  alter  the 
chemical  constitution  of  the  casein,  but  aids  digestion  by  provoking 
an  increased  flow  of  the  gastric  juice,  and  incidentally  contributes  to 
alleviate  thirst  (Jacobi). 

City  milk  should  be  boiled  to  prevent  fermentation,*  an  unnecessary 
practice  when  milk  can  be  obtained  fresh  night  and  morning.  Instead 
of  plain  water,  Jacobi  has  pointed  out  the  utility  of  using  some  sub- 
stance "  which  by  its  physical  consistence  is  able  to  hold  the  casein- 
clots  in  suspension,  thus  protecting  the  stomach  from  irritation  while 
they  are  being  prepared  for  dissolution."  I  have  been  in  the  habit  of 
following  out  to  this  end  his  earlier  suggestion,  to  employ  an  indiffer- 
ent substance,  as  gum-arabic  or  isinglass,  for  very  young  children,  and 
afterward  a  thin  decoction  of  oatmeal  or  barley,  according  to  the  tend- 
ency of  the  child  to  constipation  or  diarrhoea.  The  distress  occasioned 
in  some  cases  by  the  casein  is  often  relieved  by  subjecting  the  milk  to 
a  peptonizing  process. 

Condensed  milk  is  popular  with  many  physicians,  because  children 
with  whom  it  agrees  fatten  upon  it,  and  suffer  but  little  from  indiges- 
tion and  loose  passages.  The  large  amount  of  sugar  it  contains  un- 
fits it,  however,  for  prolonged  use.  I  have  seen  a  number  of  children 
exclusively  fed  upon  it,  after  passing  through  apparently  a  blooming 
infancy,  develop  symptoms  of  rickets  at  the  end  of  their  first  year. 
I  have,  however,  been  in  the  habit  of  allowing  its  habitual  use  during 
the  first  three  months  of  existence,  and  in  the  city  during  the  hot 
months  of  summer. 

Whatever  the  preparation  selected,  it  should  be  warmed  to  blood- 
heat  before  it  is  given  to  the  child.  A  small  quantity  of  salt  and  a 
grain  or  two  of  bicarbonate  of  soda,  or  a  tablespoonful  of  lime-water, 

*  This  object  is  best  attained  by  means  of  the  steam  sterilizer.  The  bottles  in 
this  apparatus,  after  being  filled  with  milk,  are  immersed  in  boiling  water  until 
freed  from  micro-organisms.  They  are  then  hermetically  sealed.  The  milk  when 
thus  treated  will  remain  sweet  for  days.  If  the  sterilization  be  complete,  the  milk 
will  keep  indefinitely.  The  perfection  of  the  method  immensely  reduces  the  risks 
of  bottle-feeding. 


THE   PHYSIOLOGY  AND   MANAGEMENT   OF   CHILDBED.      259 

should  be  added  to  the  infant's  food,  the  former  to  promote  assimila- 
tion, and  the  latter  to  neutralize  any  free  acid  the  milk  may  chance  to 
contain.  When  artificially  reared,  many  children  do  not  gain  flesh 
in  spite  of  apparently  healthy  digestion.  I  have  often  derived  great 
benefit,  after  the  third  month,  from  the  addition  to  each  bottle  of  a 
tablespoonful  of  Lofflund's  Liebig's  food  for  infants.  Presumably  the 
various  forms  of  malt  extracts  now  so  popular  in  this  country  would 
serve  the  purpose  equally  well. 

The  bottle  from  which  the  child  is  fed  should  be  scalded  each  time 
that  it  is  used,  and  should  then  be  filled  with  cold  water  to  which  a 
little  soda  has  been  added.  The  tube  and  mouth-piece  should  both 
be  washed,  cleaned  with  a  brush,  and  allowed  to  soak  in  cold  water 
in  the  intervals  of  feeding.  Unless  every  precaution  is  taken  to  prevent 
the  development  of  fungi,  a  bottle-fed  infant  will  never  prosper. 


THE   PATHOLOGY   OF   PREG:n:A]N^CT. 


CHAPTER  XIV. 

ACCIDENTAL   COMPLICATIONS.— ABNORMITIES  OF  THE 

UTERUS. 

Variola.  —  Rubeola.  —  Scarlatina.— Scarlatina  puerperalis.— Cholera.— Typhus,  ty- 
phoid, and  relapsing  fever.— Malarial  fever.— Icterus.— Cardiac  diseases.— Pneu- 
monia.—Emphysema,  chronic  pleurisy,  and  empyema.— Phthisis. — Syphilis. — 
Chorea. — Surgical  operations  during  pregnancy. — Double  uterus. — Ante  version 
and  anteflexion.— Retroversion. — Retroflexion. — Prolapse  of  uterus  and  vagina. 
— Hernias. 

The  pathology  of  pregnancy  includes  the  various  morbid  condi- 
tions which  exercise  an  unfavorable  influence  upon  pregnancy,  whether 
of  maternal  or  fetal  origin. 

The  maternal  diseases  comprehended  under  this  title  may  consist 
of  simple  exaggerations  of  normal  disturbances — a  class  which  has, 
however,  already  received  attention  in  connection  with  the  chapter 
on  the  management  of  pregnancy ;  accidental  complications  which 
materially  influence  the  circulation  or  the  integrity  of  the  pelvic 
organs;  and,  finally,  diseases  of  the  uterus  and  the  uterine  append- 
ages which  endanger  the  health  of  the  ovum,  or  pave  the  way  to  its 
expulsion. 

The  pathological  processes  which  affect  the  ovum  may  be  primary, 
or  may  result  secondarily  from  maternal  disturbances. 

The  haemorrhages  of  the  first  half  of  pregnancy  and  the  prema- 
ture expulsion  of  the  ovum  are  ordinarily  the  result  of  fetal  or  mater- 
nal disease.  Their  consideration,  therefore,  forms  a  fitting  conclusion 
to  the  subject-matter  in  hand. 

The  management  of  the  haemorrhages  occurring  in  the  second  half 
of  pregnancy  requires  a  preliminary  knowledge  of  the  operative  pro- 
cedures of  midwifery.  Its  consideration  will  therefore  be  postponed 
until  the  principles  governing  the  conduct  of  difficult  labor  have  un- 
dergone discussion. 

Morbid  states  which  exercise  an  unfavorable  influence  less  during 
pregnancy  than  after  the  development  of  labor  will,  to  avoid  double 
mention,  be  considered  in  connection  with  the  pathology  of  the  latter 
process. 


ACCIDENTAL  COMPLICATIONS.  261 

Accidental  Complicatioxs  of  Pkegnaxcy. 

Variola  attacks  pregnant  women  more  frequently  than  any  other 
eruptive  fever,  and,  although  it  manifests  a  preference  for  those  in 
whom  pregnancy  is  not  far  advanced,  its  type  is  severer  and  its  prog- 
nosis graver  when  it  affects  women  near  their  confinement. 

Variola  is,  unless  of  a  mild  form,  a  peculiarly  dangerous  complica- 
tion of  pregnancy,  greatly  imperiling  the  life  of  both  mother  and 
foetus,*  through  its  tendency  to  metrorrhagia  and  abortion. 

When  the  disease  pursues  its  course  without  producing  abortion, 
the  child  may  present  characteristic  variolous  cicatrices,  or  the  latter 
may  be  absent.  Occasionally  the  child  remains  unaffected  by  the  dis- 
ease until  after  birth,  and  may  sometimes  escape  it  altogether. 
During  epidemics  of  variola,  women  may,  without  manifesting  other 
symptoms  of  infection  from  the  variolous  poison,  give  birth  to  prema- 
ture children,  who  remain  unaffected  with  the  disease.  Children 
sometimes  suffer  from  variola  either  before  or  soon  after  birth,  while 
their  mothers  enjoy  complete  immunity  from  the  disease.f 

The  healthy  child  of  a  mother  affected  with  variola,  or  of  one  vac- 
cinated during  pregnancy,  may  be  insusceptible  to  vaccinia  for  some 
time  after  birth. J 

It  is  advisable  that  all  women  becoming  pregnant  during  an  epi- 
demic of  variola  should  be  immediately  vaccinated. 

Measles  is  an  infrequent  complication  of  pregnancy.  In  eleven 
cases  collected  by  Klotz,  nine  were  attended  by  premature  delivery. 
This,  according  to  Klotz,*  is  attributable  not  to  excessive  heat,  nor  to 
haemorrhagic  tendencies,  but  to  an  exanthematous  form  of  endometritis. 

Of  the  four  cases  occurring  in  his  personal  practice,  all  recovered. 
Of  sixteen  cases  collected  by  Underhill,||  in  seven  attacked  during 
pregnancy  there  were  two  deaths ;  in  seven  cases  in  which  the  attack 
occurred  at  the  end  of  pregnancy,  two  died ;  while  in  two  cases  at- 
tacked in  childbed,  both  died.  Aside  from  a  disposition  to  puerperal 
haemorrhage,  pneumonia  is  a  frequent  and  dangerous  complication. 

In  measles,  premature  delivery  is  apt  to  be  followed  by  chronic  en- 
dometritis, which,  in  case  of  renewed  pregnancy,  becomes  again  a  cause 
of  abortion.  The  poison  is  sometimes  transferred  from  the  mother  to 
the  child  during  intrauterine  existence. 

*  Meyer,  Ueber  Poeken,  beim  weiblichen  Geschlecht,  Berlin,  Beitr.  z.  Geburtsh., 
ii,  1873,  p.  197. 

t  ScHROEDER,  Lehrbuch  d.  Geburtsh.,  p.  364. 

i  Spiegelberg,  Geburtsh..  p.  259 :  jMax  Runge,  Die  acute  Iiifectionskrankheiten 
in  atiologische  Beziehung  zur  Schwangerschaftsunterbrechung,  Volkniann'sSaminl. 
klin.  Vortr.,  No.  174,  p.  1376. 

#  Klotz,  Beitrage  zur  Pathologie  der  Schwangerschaft,  Arch.  f.  Gynaek.,  voL 
xxix,  p.  449. 

I  Underbill,  Obstet.  Jour.  Great  Britain  and  Ireland.  1880,  p.  385. 


262  THE  PATHOLOGY  OF  PREGNANCY. 

Scarlatina  is  a  less  frequent  complication  of  pregnancy  than  vari- 
ola, attacks  priniipara?  by  preference,  although  not  exclusively,  and 
manifests  a  decided  tendency  to  develop  itself  in  the  puerperal  state, 
even  when  infection  has  taken  place  in  the  earlier  months  of  preg- 
nancy. Olshausen  *  was  able  to  collect  from  all  the  medical  literature 
at  his  disposal  only  seven  cases  of  scarlatina  occurring  during  preg- 
nancy, while  the  number  of  cases  taking  place  in  the  puerperal  state 
amounted  to  one  hundred  and  thirty-four. 

The  theory  that,  in  cases  of  exposure  during  pregnancy,  the  poison 
may  remain  dormant  in  the  system,  and  after  weeks  or  months  of  in- 
cubation may  break  out  in  childbed,  is  not  inherently  probable,  f 

The  mortality  of  scarlatina  occurring  in  pregnancy  and  in  the 
puerperal  state  varies  notably  in  different  epidemics.;};  Attacks  oc- 
curring immediately  after  confinement  are  more  fatal  than  those  de- 
veloped later. 

The  stage  of  invasion  may  be  entirely  absent,  or  may  exist  for  one 
or  two  days  before  the  appearance  of  the  eruption.  When  present,  it 
is  characterized  by  intense  febrile  movement,  emesis,  and  notable  con- 
gestion of  the  face.  Usually,  however,  the  earliest  announcement  of 
the  attack  consists  in  the  sudden  development  of  the  eruption  on  all 
parts  of  the  body.  In  severe  cases  the  eruption  soon  assumes  a  charac- 
teristic livid  color,  which  is  usually  retained  until  the  fatal  issue, 
should  the  latter  occur  within  a  week 

The  pharyngitis  and  tonsillitis  and  the  tongue  changes  are  either 
very  mild  or  entirely  absent.  Diarrhoea  is  a  frequent  and  dangerous 
complication.  Albuminuria  is  common.  Aside  from  the  above-men 
tioned  peculiarities,  puerperal  scarlatina  presents  no  important  vari- 
ations from  the  clinical  history  of  ordinary  scarlet  fever.  The  lochial 
discharge,  the  lacteal  secretion,  and  tlie  uterine  involution  are  un- 
affected by  the  disease 

Some  authors  have  applied  the  designation  "  scarlatina  puerperalis  " 
to  an  infectious  disease  which,  although  resembling  scarlatina,  is  still 
said  to  be  identical  with  or  closely  related  to  puerperal  fever.  The 
theory  advocated  by  them  is  based  upon  the  fact  that,  in  the  cases 
upon  which  their  deductions  are  founded,  the  angina  was  trivial  in 
character ;  the  attacks  occurred  usually  within  three  days  after  con- 
finement ;  infection  with  scarlatinus  jjoison  could  not,  in  the  majority 
of  cases,  be  established ;  the  rate  of  mortality  was  very  high,  and  peri- 

*  Olshausen,  Untersueh.  iiber  d.  Complic.  des  Puerp.  rait  Scarlat.  und  die 
sogenannte  S.  puerperalis,  Arch.  f.  Gynaek.,  ix,  1876,  p.  169 ;  Braxton  Hicks,  Trans, 
of  the  Obstet.  Soc.  of  London,  vol.  xvii. 

t  Vide  BoxALL,  Obstet.  Trans,  of  London,  vol.  sxx ;  L.  Meyer,  Zeitschr.  fur 
Geb.  und  Gynaeii.,  vol.  xiv,  p.  289. 

X  Denham  saw  only  one  recovery  in  eight  and  Hicks  only  four  reeoveri^  in 
eighteen  cases ;  MeClintock  had  ten  fatal  results  in  thirty-four  cases  ;  Boxall,  six- 
teen cases  with  no  deaths ;  L.  Meyer,  eighteen  cases  with  one  death. 


ACCIDENTAL   COMPLICATIONS.  263 

tonitis  and  cellulitis  were  often  revealed  on  autopsy.  Olshausen* 
concludes  with  apparent  justice,  after  a  careful  review  of  the  reasons 
for  and  against  the  introduction  of  this  new  disease  into  obstetric  nosol- 
ogy, that  the  grounds  for  its  establishment  are  insufficient,  and  that 
the  cases  of  so-called  "  scarlatina  puerperalis  "  are  nothing  more  than 
ordinary  cases  of  scarlet  fever  modified  by  the  concomitant  puerperal 
condition,  but  in  no  way  akin  to  puerperal  pyaemia  or  septica?mia.  It 
is  worthy  of  note,  that  scarlatina  and  puerperal  fever  may  occur  in 
combina'tion  without  mutually  affecting  their  respective  signs  and 
symptoms.  Braxton  Hicks  f  advocates  the  extreme  theory  that  a 
puerperal  woman  when  infected  with  scarlatina  develops  puerperal 
fever,  and  that  persons  other  than  lying-in  women  contracting  the  dis- 
ease through  intercourse  with  the  puerperal  patients  are  attacked  by 
scarlatina  of  the  usual  form. 

Antipyretic  measures,  particularly  cool  baths,  are  indicated  in  pro- 
portion to  the  intensity  of  the  febrile  movement.  Cathartics  are  to  be 
avoided,  because  of  the  inherent  tendency  to  diarrhoea,  alluded  to 
above.  Special  attention  should  be  paid  to  the  treatment  of  septic 
symptoms  where  these  coexist. 

Cholera. — The  predisposition  on  the  part  of  ])regnant  and  puer- 
peral women  to  cholera  Asiatica  is  not  usually  decided,  but  varies 
with  different  epidemics,  and  is  more  marked  in  cities  than  in  the 
country.  Women  are  most  liable  to  an  attack  of  cholera  in  the  latter 
half  of  pregnancy,  particularly  in  the  seventh  and  eighth  months,  and 
the  prognosis  is  gravest  for  cases  occurring  at  those  periods.  The 
prognosis  is  almost  necessarily  fatal  in  the  case  of  children  born  before 
the  ninth  month.;);  The  intensity  of  the  disease  is  somewhat  mitigated 
by  the  existence  of  the  puerperal  state.  Slight  attacks  of  cholera  may 
take  their  natural  course  without  prejudicial  effects  upon  mother  or 
foetus,  but  the  disease  frequently  results  in  abortion  or  premature  de- 
livery, due  in  part  to  hasmorrhagic  metritis.  The  pathological  uterine 
conditions  observed  in  the  cases  recorded  by  Slavjansky  ^  comprised 
roughening  of  the  inner  surface  of  the  uterus  by  dark-violet  shreds  of 
the  decidua  vera,  numerous  extravasations  permeating  the  mucous 
membrane,  which  remained  intact  in  some  places  and  was  ulcerated  at 
others,  besides  the  presence  in  the  uterine  cavity  of  coagulated  blood, 
pus,  and  shreds  of  the  uterine  mucous  membrane. 

The  placenta  fetalis  presented  granular  degeneration  and  almost 
complete  disintegration  of  the  epithelium  covering  the  villi.     Both  of 

*  R.  Olshausen,  Ioc.  cit. 

f  BraxtOxV  Hicks,  Trans,  of  the  Obstet.  Soc.  of  London,  1871,  pp.  44,  75. 
i  Ueber  d.  Einfluss  d.  C.  auf  Schw.  u.  Woehenbett,  Monatsschr.  f.  Geburtsh.,  1868, 
xxxii,  p.  60. 

*  Slavjansky,  Endometrit.  decidualis  haem.  bei  Cholerakranken,  Arch.  f.  Gy- 
naek.,  iv,  1872,  p.  293. 


264 


THE   PATHOLOGY   OF   PREGNANCY. 


the  pathological  processes  above  described  conspire  to  induce  the  death 
of  the  foetus,  which  then,  in  common  with  coagula  and  inflammatory 
products  in  the  uterine  cavity,  acts  as  a  foreign  body  and  produces 
abortion.  Schroeder  *  refers  the  death  of  the  foetus  to  asphyxia  pro- 
duced by  changes  in  the  maternal  blood  which  interfere  with  the  pla- 
cental respiratory  function.  The  clinical  history  of  cholera  is  not 
materially  affected  by  coexisting  pregnancy,  except  in  so  far  as  uterine 
symptoms  are  concerned.  Eclampsia  sometimes  occurs,  and  irregular 
uterine  pains  may  persist  for  several  days  without  producing  ab'ortion.f 
Cholera  does  not  specially  predispose  to  puerperal  diseases,  nor  does 
it  afford  protection  against  them.  Lactation,  whether  commencing  or 
already  established,  is  not  markedly  affected  by  cholera,  although  the 
lochia  are  often  almost  suppressed. 

The  treatment  is  conducted  upon  general  principles.  The  artifi- 
cial induction  of  premature  delivery  has  had  many  advocates,  on  ac- 
count of  its  supposed  tendency  to  ameliorate  the  prognosis,  but  has 
now  fallen  into  disrepute,  although  Judicious  measures  to  hasten  par- 
turition, already  begun  bv  nature,  are  regarded  as  justifiable. 

Typhus,  Typhoid,  and  Relapsing  Fevers. — These  fevers  more  fre- 
quently complicate  the  earlier  than  the  later  months  of  I3regnancy, 
and  affect  the  prognosis  more  seriously  at  the  former  epoch,  owing  to 
the  greater  tendency  then  existing  to  protracted  jjost-partiwi  haimor- 
rhage.J     They  may  also,  rarely,  complicate  the  puerperal  state. 

Typhus  fever  manifests  a  less  marked  tendency  to  the  induction  of 
abortion  or  of  premature  delivery  than  either  typhoid  or  relapsing 
fever,  probably  because  it  is  less  frequently  accompanied  by  metrorrha- 
gia.* It,  however,  occasionally  produces  these  results,  thereby  essen- 
tially increasing  the  danger  of  a  lethal  termination. || 

Typhoid  fever  is  frequently,  and  relapsing  fever  almost  constantly, 
accompanied  by  abortion  or  by  premature  delivery  induced  by  profuse 
uterine  haemorrhages,"^  and  thus  greatly  endanger  life.  The  clinical 
history  and  the  treatment  of  the  fevers  in  question  are  unaffected  by 
coexisting  pregnancy  except  in  so  far  as  symptoms  and  indications 
having  reference  to  the  occurrence  of  metrorrhagia,  abortion,  or  pre- 
mature delivery,  are  concerned. 

Malarial  Fever. — Malarial  fever  is  not  a  very  frequent  complication 
of  pregnancy,  perhaps  because  the  latter  secures  a  certain  freedom 
from  exposure  to  the  malarial  poison.  Women  who  have  previously 
experienced  malarial  fever,  and  who  have  been  considered  cured  of  the 
disease  for  several  years,  often  suffer  a  relapse  during  subsequent  preg- 

*  Schroeder,  Lehrb.  d.  Geburtsh.,  1873,  p.  365.  -f-  Hennig,  loc.  cit. 

X  Wallichs,  Monatsschr.  f.  Geburtsk.,  xxx,  H.  iv,  1867,  p.  353 ;  Spiegelbbrg, 
Handb.  d.  Geburtsh.,  p.  360. 

*  Zuelzer,  Monatsschr.  f.  Geburtsk.,  xxxi,  H.  vi,  1868,  p.  419. 

U  Wallichs,  op.  cit,  p,  361.  ^  Zuelzer,  op.  cif.,  p.  434. 


ACCIDENTAL   COMPLICATIONS.  265 

nancies.*  Attacks  occurring  under  these  circumstances  may  be  re- 
garded as  acute  exacerbations  of  a  chronic  malarial  disease  which  has 
remained  latent  for  a  certain  time.  Malarial  fever,  according  to 
Runge,t  Ritter,^  and  most  observers  in  this  country,  does  not  produce 
abortion  except  iu  rare  instances,  even  when  the  febrile  phenomena 
persist  up  to  the  termination  bf  pregnancy  ;  though  Goth  *  has  re- 
ported forty-six  cases,  in  nineteen  of  which  either  abortion  or  premature 
delivery  took  place.  Parturition  usually  suspends  the  periodic  parox- 
ysms, supposing  them  to  have  continued  up  to  confinement,  possibly 
owing  to  the  loss  of  blood  dependent  on  delivery,  but  the  rule  is  not 
without  exceptions.  During  the  puerperal  state,  however,  particularly 
in  the  second  and  third  weeks,  the  paroxysms  usually  return,  or  a  latent 
malarial  cachexia  may  manifest  itself  in  the  manner  previously  alluded 
to.  I  The  disease  may  be  communicated  to  the  foetus,  as  has  been 
proved  by  the  detection  of  the  characteristic  pathological  appearances 
induced  by  malarial  poisoning  in  the  spleen,  and  by  the  discovery  of 
malarial  pigment-granules  in  the  blood  and  skin  of  children  dying  be- 
fore or  immediately  after  birth.^ 

Hubbard^  reported  an  interesting  case  of  intra-uterine  malarial 
fever  of  the  tertian  type,  in  which  the  fetal  movements  were  entirely 
suspended  during  the  maternal  paroxysms,  and  returned  during  the 
intermissions.  The  woman  was  confined  during  an  intermission.  On 
the  following  day  the  mother  and  child  had  a  simultaneous  paroxysm. 
Quinia  was  now  administered,  with  the  result  of  curing  both  mother 
and  child — the  latter  obtaining  the  antiperiodic  through  the  medium 
of  the  mother's  milk. 

The  usual  course  of  malarial  fever  is  altered  by  coexisting  preg- 
nancy. Intermissions  are  usually  wanting,  and  the  fever  becomes 
continued  or  remittent,  the  chills  occurring  irregularly. J  Even  those 
cases  which  most  nearly  approximate  the  usual  malarial  course  show 
a  tendency  to  anticipation  or  retardation  of  the  paroxysms.  The  fever 
may  assume  a  pernicious  character,  its  tendency  in  this  direction  being 
accounted  for  by  the  nervous  prostration  and  autemia  attendant  upon 
the  puerperal  condition.  Quinia  best  controls  the  febrile  phenomena, 
but  must  be  given  in  large  doses,  since  the  powers  of  digestion  and  of 
assimilation  are  seriously  impaired  by  the  puerperal  state.|; 

*  Robert  Barnes.  Trans,  of  the  Am.  Gyn.  Soc.  1876,  p.  144. 

t  Max  Runge.  Volkmann's  Samml.  klin.  Voi-tr..  No.  174,  p.  10. 

i  RiTTER,  Studien  iiber  Malaria-Infection,  Virch.  Arch.,  vol.  xxxix,  p.  14. 

«  Goth,  Ueber  tlen  Einfluss  der  Malaria-Infection  auf  Schwangerschaft,  Geb. 
und  Woehenbett,  Ztschr.  f.  Gebh.  und  Gynaek.,  vol.  ri,  p.  17. 

II  Spiegelberg.  Gebui-tsh.,  p.  261.  ^  Max  Runge,  loc.  cit. 

{>  Hubbard.  Edinburgh  Med.  Jour.,  June,  1866. 

i  Mendel,  Intermittens  wahrend  Schwangerschaft  und  Woehenbett,  Monatsschr. 
f.  Geburtsk.,  Bd.  xxxii,  H.  i,  p.  10. 

%  Barker,  in  a  paper  termed  Puerperal  Malarial  Fever  (Am.  Jour,  of  Obstet., 


266 


THE  PATHOLOGY  OP  PREGNANCY. 


Icterus.— Icterus,  although  a  i3henomeuon  of  rare  occurrence  dur- 
ing pregnancy,  is  interesting  and  important  on  account  of  its  tendency 
to  precede  or  to  accompany  the  fatal  pathological  changes  and  symp- 
tomatic events  connected  with  acute  yellow  atrophy  of  the  liver.  It 
is  ordinarily  assumed  that  this  grave  general  disease  is  developed  from 
a  form  of  icterus  which,  when  compRcating  pregnancy,  usually  has 
etiological  relations  identical  with  those  of  simple  obstructive  or  so- 
called''  hepatic  jaundice,  although  the  causative  condition  frequently 
eludes  observation.  The  development  in  pregnancy  of  icterus  termi- 
nating fatally  is  also  sometimes  due  to  the  lesions  of  phosphorus- 
poisoning.  Davidson*  attributes  the  fatal  influence  of  pregnancy 
upon  the   course   of  simple  icterus   to   the  three   following  causes: 

1.  The  impairment  of  the  renal  excretory  function,  due  to  the  passive 
congestion  produced  by  uterine  pressure  upon  the  renal  veins.  This 
etiological  factor  operates  by  causing  the  retention  in  the  blood  of  the 
reabsorbed  biliary  acids,  which,  according  to  the  investigations  of 
Traube  and  others,  are  of  themselves  capable,  even  when  present  in 
the  blood  in  moderate  quantity,  of  producing  acute  yellow  atrophy. 

2.  The  hydraemia  of  pregnancy,  which  renders  the  system  less  capable 
of  resistance  to  toxic  agencies.  3.  The  impairment  of  cardiac  activ- 
ity, due  to  the  retention  of  the  biliary  acids,  which  still  further  com- 
promises renal  eliminative  action.  Icterus  often  produces  abortion  by 
destroying  the  life  of  the  foetus.  The  causative  connection  between 
icteius  and  fetal  death  has  been  proved  by  the  intense  icterus  of  the 
dead  foetus,  by  the  detection  of  biliary  acids  in  its  blood,  and  by  the 
exclusion  of  other  causes.  After  abortion  a  previously  benign  icterus 
may  speedily  develop  all  the  characteristic  lesions  and  symptoms  of 
acute  yellow  atrophy. f  Under  these  circumstances  the  sudden  advent 
of  the  fatal  symptoms  may  be  accounted  for  by  the  anajmia  and  hy- 
drsemia  induced  by  the  ha?morrhage  accompanying  parturition.  As- 
suming the  correctness  of  the  above-mentioned  deductions  with  refer- 
ence to  the  usual  etiology  of  fatal  icterus  complicating  pregnancy, 
we  must  admit  the  urgent  indication  in  these  cases  for  measures  cal- 
culated to  facilitate  the  elimination  of  the  biliary  acids  from  the  blood 
by  restoring  the  normal  excretory  function  of  the  kidneys.  An  early 
resort  to  appropriate  measures  might,  partially  or  entirely,  prevent  the 
accumulation  of  the  poison  upon  whose  presence  such  baneful  results 
are  believed  to  depend. 

Cardiac  Diseases. — The  various  effects  produced  upon  pregnancy 
by  coexisting  heart-disease  depeiid  entirely  upon  the  seat  and  character 
of  the  cardiac  affection.     While  the  results  of  myocarditis  are  serious, 

April,  1880),  furnishes  a  most  valuable  addition  to  our  knowledge  of  the  symptome 
and  treatment  of  this  disease. 

*  Davidson,  Monatsschr.  f.  Geburtsk.,  Bd.  xxx,  H.  vi,  1867,  p.  465. 

t  ScHROEDER,  Lehrbuch  der  Geburtsh.,  p.  366. 


I 


ACCIDENTAL  COMPLICATIONS. 


267 


because  of  its  interference  with  the  development  of  cardiac  hyper- 
trophy adequate  for  the  compensation  of  existing  valvular  lesions,  and 
acute  endocarditis,  occurring  during  pregnancy,  shows  a  marked  tend- 
ency to  assume  the  fatal  ulcerative  form,*  pericarditis  has  no  percep- 
tible effect  upon  the  normal  course  of  utero-gestution.f  Chronic  en- 
docarditis often  produces  disastrous  results,  which  may,  in  general 
terms,  be  accounted  for  by  the  fact  that  an  amount  of  cardiac  hyper- 
trophy completely  compensatory  for  pre-existing  valvular  lesions  is  no 
longer  able  to  overcome  the  increased  arterial  and  venous  pressure 
prevailing  during  pregnancy,  or  to  adapt  itself  to  the  sudden  variations 
in  vascular  tension  due  to  the  parturient  act.  The  augmented  arterial 
pressure  which  calls  for  increased  cardiac  activity  is  referable,  in  part, 
to  the  newly  developed  utero-placental  circulation.  It  is  also  attrib- 
uted by  some  authors  to  the  actual  pressure  of  the  gravid  uterus  upon 
the  aorta ;  while  Spiegelberg  J  believes  it  to  be  measurably  due  to  the 
plethora  of  pregnancy,  and  to  the  limitation  of  the  intra-thoracic  space 
by  the  encroachments  of  the  diaphragm.  An  important  source  of 
varying  and  perturbed  heart-action  is,  moreover,  found  during  labor  in 
the  suddenly  changing  conditions  of  pressure  produced  by  the  alter- 
nating uterine  contractions  and  relaxations  with  the  corresponding 
violent  respiratory  efforts. 

Spiegelberg*  refers  the  symptoms  of  aortic  insufficiency  or  stenosis, 
which  are  usually  most  marked  in  the  later  months  of  pregnancy, 
solely  to  cardiac  disturbances  due  to  increased  arterial  tension,  and  the 
disappearance  of  these  symptoms  after  birth  to  the  restitution  of  the 
normal  pressure.  McDonald  ||  refers  the  improvement  not  so  much  to 
the  diminution  of  the  arterial  tension  as  to  the  absence  of  the  extra 
tension  associated  with  the  bearing-down  effort.  Spiegelberg  considers 
the  grave  symptoms  of  mitral  disease  often  presenting  themselves 
soon  after  confinement  as  referable  to  excessive  distention  of  the 
right  heart  with  blood  forced  into  it  from  the  contracted  uterus. 
Fritsch^  opposes  this  view,' and  attributes  the  morbid  phenomena  of 
mitral  disease  to  the  accumulation  of  blood  in  the  abdominal  vessels 
recently  released  from  the  pressure  of  the  gravid  uterus,  and  to  the 
cardiac  paralysis  resulting  from  an  insufficient  blood-supply  and  con- 
sequent defective  nutrition  of  the  heart. 

The  hydremia  of  the  puerperal  state  may  contribute  to  the  impair- 

*  Lebert,  Beitr.  zur  Casuistik  der  Herz-  und  Gefaf5skrankheiten  im  Puerperium, 
Arch.  f.  Gynaek.,  Bd.  iii,  1872,  p.  39. 

•(■  PoRAK.  De  Tinfl.  recip.  de  la  grossesse  et  des  mal.  de  coeur,  1880.  p.  92. 
X  Spiegelberg,  Ueber  d.  Comp.  des  Puerp.  m.  chron.  Herzkr.,  Arch.  f.  Gynaek., 
ii,  1871,  p.  236. 

*  Spiegelberg,  ibid.,  p.  233. 

II  McDonald,  Heart  Disease  during  Pregnancy,  Parturition,  and  Childbed, 
p.  47. 

^  Fritsch,  DieGefahren  d.  MitralLsfehler,  ibid.,  viii.  1875.  p.  .-JSl. 


2fi8 


THE  PATHOLOGY  OF  PREGNANCY. 


meut  of  nutrition,  and  thus  co-operate  with  the  abo^e  causative  agen- 
cies in  the  production  of  cardiac  paralysis. 

Fresh  inflammatory  affections  may  attack  the  valves  and  endocar- 
dium of  a  heart  already  weakened  by  disease.  This  occurs  by  prefer- 
ence in  cardiac  cases  of  more  recent  origin.  In  all  cases  of  heart 
disease,  and  especially  in  those  with  acute  symptoms,  there  is  great 
danger  of  embolism.  Slight  exposure  to  cold  and  exertion  in  preg- 
nant patients  with  cardiac  diseases  is  liable  to  occasion  pulmonary  dis- 
turbances.    These  appear  usually  in  the  second  half  of  pregnancy.* 

The  symptoms  of  aortic  valvular  disease  are  usually  manifested 
during  the  latter  half  of  pregnancy.  They  consist  in  palpitations, 
dyspnoea,  and,  in  extreme  cases,  in  abortion  or  premature  delivery. 
Should  pregnancy  proceed  to  a  normal  termination,  the  symptoms  are 
aggravated  by  parturition,  and  syncope  is  of  common  occurrence,  but 
the  symptoms  disappear  speedily  after  labor  is  ended.  Mitral  valvular 
lesions,  if  slight  or  completely  compensated  for,  may  not  manifest 
their  existence  by  any  rational  symptoms.  If,  however,  the  compen- 
sation bo  inadequate,  the  patient's  life  may  be  greatly  and  sometimes 
suddenly  endangered  by  the  occurrence,  either  before  or  after  confine- 
ment, of  extreme  pulmonary  congestion  and  oedema,  ascites,  albumi- 
nuria, or  metrorrhagia.  The  foetus  may  die  in  utero,  as  the  result  of 
metrorrhagia  or  of  impaired  nutrition  due  to  deficient  oxygenation  of 
the  maternal  blood.  Children  whose  mothers  are  the  victims  of  car- 
diac disease  are  often  imperfectly  developed,  and  predisposed  to  un- 
timely death.  The  prognosis  is  based  upon  the  general  conditions  of 
the  patient.  In  seventeen  of  the  thirty-one  cases  collected  by  McDon- 
ald the  patients  died.  The  prognosis  is  impaired  by  coexisting  pul- 
monary lesions,  tending  to  obstruct  the  circulation  in  the  lungs,  as 
well  as  by  diseases  of  other  vital  organs.  Mitral  lesions  are  of  more 
grave  significance  than  those  at  the  aortic  orifice,  and  mitral  stenosis 
is  particularly  dangerous,!  because  of  its  tendency  to  produce  dilata- 
tion of  the  left  auricle  and  the  heart. 

Women  with  cardiac  disease  of  any  considerable  gravity  should  be 
dissuaded,  from  marriage.  The  indications  for  medicinal  treatment 
are  the  same  as  for  cardiac  diseases  uncomplicated  by  pregnancy. 
Chloroform  should  be  administered  with  special  caution  during  partu- 
rition. McDonald,  however,  believes  that,  cautiously  administered  in 
the  second  stage,  chloroform  is  useful  by  diminishing  the  down-bearing 
efforts.  In  order  to  lessen  the  latter,  the  same  author  urges  as  of  ex- 
treme importance  the  timely  application  of  the  forceps,  or  the  perform- 
ance of  version  in  suitable  cases,  should  the  second  stage  be  in  any  way 
prolonged.  The  artificial  induction  of  abortion  or  of  premature  de- 
livery is  justified  only,  according  to  McDonald,  in  cases  where,  as  in 
hydramnion,  the  abdomen  is  unduly  distended. 

*  McDonald,  I.  c,  pp.  199, 200.       f  Porak,  op.  cit.,  p.  113  ;  Fbitsch,  op.  cit,  p.  383. 


ACCIDENTAL   COMPLICATIONS.  269 

Acute  Lobar  Pneumonia. — Pneumonia  attacks  women  less  fre- 
quently thau  men.  Its  rate  of  mortality  is,  however,  much  larger 
among  the  former.  These  facts  should  be  remembered  by  investi- 
gators of  the  reciprocal  relations  between  pneumonia  and  pregnancy, 
in  order  that  the  influence  exerted  by  the  former  upon  the  latter  be 
not  exaggerated.  Pneumonia  is  an  infrequent  comj^lication  of  the 
pregnant  state,  but  affects  the  course  of  the  latter  very  prejudicially  * 
Although  a  pneumonia  of  large  extent  may  terminate  in  complete 
recovery  without  having  endangered  tlie  life  of  mother  or  foetus,t  it 
often  produces  abortion  or  premature  delivery,  the  frequency  of  these 
results  increasing  in  direct  proportion  to  the  duration  of  pregnancy. 
The  type  of  the  pulmonary  inflammation  is  also  more  severe  in  the 
later  stages  of  utero-gestation,  and  parturition  exerts  an  unfavorable 
effect  upon  women  in  proportion  as  their  pregnancy  is  far  advanced.| 

It  was  formerly  believed  that  pneumonia,  occurring  during  preg- 
nancy, owed  its  fatal  character  chiefly  to  the  encroachments  of  the 
gravid  uterus  upon  the  intra-thoracic  space,  and  to  the  consequent 
interference  with  the  necessary  compensatory  increase  of  functional 
activity  on  the  part  of  the  healthy  lung-tissue.  Later  investigations 
having  not  only  shown  the  fallacy  of  this  theory,*  but  even  rendered 
jirobable  an  actual  increase  in  the  intra-thoracic  space  during  preg- 
nancy,! the  fatal  character  of  intercurrent  pneumonia  is  referred  to 
coexisting  hydremia,  and  to  the  inability  of  the  poorly  nourished 
heart  to  restore  the  balance  of  a  pulmonary  circulation  disturbed  by 
the  consolidation  of  lung-tissue  and  by  the  consequent  impermeabil- 
ity of  large  capillary  areas.  Pulmonary  oedema,  resulting  trom  pro- 
gressive cardiac  asthenia,  directly  induces  the  fatal  issue.  Parturition 
itself,  whether  naturally  or  artificially  produced,  greatly  imperils  the 
woman's  life"^  by  making  exorbitant  demands  upon  the  already  failing 
heart-power  and  by  aggravating  existing  hydraemia.  Abortion,  when 
occurring  under  these  circumstances,  is  referred  to  fetal  death  caused 
by  deficient  oxygenation  of  the  maternal  blood,  by  placental  anemia 
produced  through  an  inadequate  supply  of  blood  to  the  left  heart,  and 
by  the  abnormally  elevated  maternal  temperature.^  From  the  fatal 
results  of  parturition  in  pneumonia  we  conclude  that  the  induction 
of  abortion  or  of  premature  delivery  in  ordinary  cases  is  unjustifi- 
able.J  Should  labor,  however,  have  already  begun,  Its  termination 
must  be  hastened  by  all  available  means.     Our  further  treatment  must 

*  Pasbexder,  Ueber  P.  als  Sehwangersch.  Complicat.,  etc.,  Beitrag.  z.Geburtsh.. 
hi,  1874,  Silzgsber.,  p.  54. 

t  GussEROw,  Pn.  b.  Schwangeren,  Moniitsschr.  f.  Gebiirtsk.,  xxxii,  H.  ii,  1868,  p.  93. 
t  Werxich,  Beitrag.  z.  Geburtsh.,  iii.  1874,  Sitzgsb.,  p.  56. 

*  GussEROw,  op.  cit.,  p.  88. 

II  Wernich,  Berlin.  Beitrag.  z.  Geburtsh.,  ii,  1873.  p.  249. 

^  Fasbexder.  op.  cit.,  p.  55.  0  Spiegelberi;,  Lehrb.  d.  Geburtsli.,  i>.  2G~u 

J  Werxich,  op.  cit.,  p.  2C1. 


270  THE  PATHOLOGY  OP  PREGNANCY. 

consist  in  efforts  at  strengthening  the  heart's  action.  Brandy  and  car 
bonate  of  ammonia,  digitalis  and  quinia,  deserve  the  most  confiden(;e 
for  the  fulfillment  of  these  indications.  Wernich  recommends  cautious 
venesection  for  tlie  relief  of  extreme  dyspnoea  or  cyanosis,  and  pro- 
poses that  the  collapse  to  which  bloodletting  may  lead  be  combated  by 
transfusion.* 

Emphysema,  Chronic  Pleurisy,  and  Empyema.— These  affections  are 
dangerous  complications  of  pregnancy,  in  that  they  produce  cardiac 
dilatation  and  prevent  the  heart  from  successfully  adapting  its  activity 
to  the  varying  conditions  of  vascular  tension  obtaining  in  parturition 
and  the  puerperal  state.  The  induction  of  abortion  or  of  premature 
delivery  may  be  indicated  by  the  existence  of  these  diseases,  provided 
the  mother's  strength  has  become  so  impaired  as  to  incapacitate  her 
for  continued  utero-gestation. 

Phthisis. — It  was  formerly  erroneously  held  that  pregnancy  afforded 
immunity  against  pulmonary  phtliisis.  This  view  may  have  been 
based  upon  the  clinical  fact  that  the  progress  of  pre-existent  phthisis 
is  sometimes  retarded  by  the  supervention  of  pregnancy. f  This  re- 
sult is  observed,  according  to  Lebert,J  in  only  a  small  proportion  of 
cases.  In  the  majority  of  instances,  pregnancy  not  only  hastens  the 
progress  of  actually  existing  phthisis  but  precipitates  its  development. 
The  latter  result  is  of  especially  frequent  occurrence  in  those  heredi- 
tarily predisposed  to  the  disease,  or  in  such  persons  as  may  have  re- 
covered from  a  previous  attack.  These  effects  of  pregnancy  upon  the 
development  and  course  of  phthisis  are  most  manifest  between  the 
ages  of  twenty  and  thirty  years,  although  they  are  not  infrequent  be- 
tween the  ages  of  thirty  and  forty.  The  advanced  stages  of  phthisis 
prevent  conception,  but  the  same  is  not  true  of  its  earlier  periods.  The 
puerperal  state  often  favors  the  development  of  phthisis,  particularly 
in  those  hereditarily  predisposed  to  it,  and  usually  hastens  the  fatal 
issue  of  the  disease  if  it  has  already  manifested  itself.  In  very  excep- 
tional instances,  however,  parturition  and  the  post-partum  state  exert 
a  favorable  influence  upon  the  course  of  phthisis.  It  often  happens 
that  women  with  inherited  tendencies  to  phthisis  may  escape  it  during 
their  first  pregnancy,  only  to  become  its  victims  in  a  later  one.*  Al- 
though women  with  progressing  phthisis  may  pass  through  the  partu- 
rient and  puerperal  states  in  safety,  they  are  greatly  prostrated  thereby, 
and  rarely  have  sufficient  milk  to  nurse  their  children.  They,  more- 
over, often  experience  abortion  or  premature  delivery.  The  children 
of  such  women  are  usually  puny  and  feeble.     They  are  slowly  and  im- 

*  ScHROEDER,  Lehrb.  d.  Geburtsh.,  p.  364. 

t  Wernich,  Berlin.  Beitrag.  z.  Geb.,  ii,  1873.  p.  251. 

X  Lebebt,  Ueber  Tab.  d.  weiblich.  Geschlechtsorgane,  Arch.  f.  Gynaek.,  iv,  1872, 
p.  469. 

*  Spiegelberg,  Lehrb.  d.  Geburtsh.,  p.  266. 


I 


ACCIDENTAL  COMPLICATIONS.  271 

perfectly  developed,  and  are  predisposed  to  pulmonary  disease.  Prophy- 
lactic treatment  affords  the  only  encouraging  prospects  of  success  in 
the  cases  under  consideration.  Girls  with  suspected  hereditary  predis- 
position to  phthisis  should,  accordingly,  not  marry,  as  they  should  not 
become  mothers.  If  they  do  bear  children,  they  must  never  nurse 
them. 

SjrpMlis. — When  syphilis,  which  is  a  frequent  complication  of  preg- 
nancy, is  contracted  at  the  beginning  or  during  the  course  of  the  latter, 
it  is  characterized  by  intense  initial  and  by  unusually  mild  consecutive 
symptoms.*  The  duration  of  the  incubation  is  ordinarily  about  two 
weeks,  but  may  be  protracted  to  six  weeks.  The  initial  lesions,  which 
are  more  extensive  than  in  women  who  are  not  pregnant,  may  involve 
the  vagina,  cervix,  labia,  nates,  and  thighs.  They  embrace  swelling, 
reddening,  and  excoriation  of  the  mucous  membrane  and  skin,  oedema, 
eczema,  follicular  abscesses,  and  even  necrosis  of  connective  tissue. 
These  intense  inflammatory  processes  may  be  referred  to  increased 
nutrition  of  the  parts,  and  to  the  mechanical  results  of  friction  between 
them.  The  secondary  symptoms  are  of  a  mild  type,  consisting  chiefly 
of  general  glandular  induration,  papules  on  and  around  the  genitals, 
and  scales  on  the  palms  and  soles.  Mewis  f  states  that  the  occurrence 
of  parturition  has  a  favorable  effect  upon  these  lesions,  usually  result- 
ing in  their  disappearance.  Erythema,  pharyngitis,  alopecia,  iritis,  and 
febrile  movement  are  either  absent  or  slightly  marked.  Pregnant 
women  owe  the  mildness  of  their  secondary  symptoms  to  amelioration 
of  their  general  nutrition.  Syphilis  exerts  a  very  prejudicial  influence 
upon  the  product  of  conception.  If  either  parent  be  affected  with 
general  syphilis  at  the  time  of  the  coition  resulting  in  impregnation, 
syphilis  is  communicated  to  the  foetus.  It  is  almost  equally  impos- 
sible for  a  foetus  poisoned  by  the  paternal  reproductive  element  to 
infect  a  healthy  mother.  Provided  the  mother  were  untainted  at  the 
time  of  conception,  syphilis  contracted  by  her  during  pregnancy  is 
rarely  communicated  to  the  foetus.  If  the  father  be  syphilitic,  the 
infection  of  the  ovum  is  accomplished  by  the  diseased  spermatozoids. 
If  the  mother  be  constitutionally  tainted,  the  ovum  is  already  poi- 
soned. Should  both  parents  be  the  victims  of  general  syphilis,  each 
equally  bequeaths  the  disease  to  the  offspring.  It  is  probable,  too,  that 
the  syphilitic  poison  can  traverse  the  septa  intervening  between  the 
fetal  and  the  maternal  vascular  systems. J 

A  progressive  and  continuous  diminution  in  the  intensity  of  fetal 

*  SiGMUND,  Ueber  d.  Verlauf.  d.  S.  bei  Schwangerschaft,  Wien.  med.  Presse.  xiv, 
1873,  No.  1. 

t  Mewis,  Syphilis  congenita,  Ztschr.  f.  Geburtsh.  u.  G>Tiaek.,  iv,  1879,  I,  p.  62. 

X  Professor  McLane,  of  this  city,  has  reported  to  me  the  history  of  a  well- 
observed  case,  where  error  was  hardly  possible,  in  which  the  mother,  previously 
healthy,  was  infected  in  the  fourth  month,  and  gave  birth  in  the  ninth  month  to  a 
dead  child  with  well-marked  syphilitic  lesions. 


272  THE  PATHOLOGY  OF  PREGNANCY 

syphilis,  directly  proportionate  to  the  length  of  time  which  has  elapsed 
since  the  contraction  of  the  disease  by  the  parent  who  communicated 
it,  is  observed  in  cases  unmodified  by  treatment.  Parents  whose 
syphilis  is  allowed  to  pursue  its  natural  course  retain  the  capability 
of  transmitting  the  disease  to  their  offspring  for  varying  periods, 
the  average  length  of  which  is  ten  years.  Latency  of  the  parental 
syphilis  does  not  secure  immunity  of  the  foetus  from  the  disease. 
although  it  diminishes  the  probability  of  its  transmission.  Parents 
with  tertiary  syphilitic  symptoms  may  or  may  not  communicate  the 
disease  to  their  children,  according  as  the  poison  whose  original  pres- 
ence produced  the  gummata  is  still  retained  in  the  system  or  has 
been  eliminated  by  nature  or  by  mercurials.  In  accordance  with  the 
varying  intensity  of  the  hereditary  influence,  the  foetus  may  either 
perish  in  utero,  its  death  resulting  in  abortion  or  premature  delivery, 
may  be  born  alive  but  destined  to  die  early,  or  may  manifest  the  dis- 
ease only  at  the  expiration  of  periods  varying  from  weeks  to  months. 
Conception  occurring  during  the  first  years  after  the  parents'  infec- 
tion with  syphilis  almost  invariably  terminates  in  abortion  or  prema- 
ture delivery,  the  causes  of  which  are  either  the  vitiated  nutritive 
processes  of  the  foetus,  the  increased  maternal  temperature  due  to 
syphilitic  fever,  or  syphilitic  degeneration  of  the  fetal  placenta,  con- 
sisting, according  to  Mewis,*  of  inflammatory  changes  in  the  tunica 
intima  of  the  blood-vessels.  Similar  pathological  changes  are  said,  by 
the  same  author,  to  occur  in  the  intima  of  the  umbilical  vessels.  The 
pathological  conditions  observed  in  syphilitic  disease  of  the  placenta 
are  either  granular  degeneration  of  the  placental  villi,  with  obliteration 
of  the  blood-vessels,  or  the  morbid  changes  designated  by  the  names 
endometritis  placentaris  gummosa  and  endometritis  decidualis.f  (For 
a  more  detailed  account  of  placental  syphilis,  vide  chapter  on  placental 
diseases.) 

Every  pregnant  woman  who  at  the  time  of  conception  is  or  has 
been  affected  with  constitutional  sypliilis,  should  be  promptly  sub- 
jected to  a  thorough  mercurial  treatment,  preferably  by  the  method 
of  inunction.  This  is'  desirable  even  when  no  present  symptoms  are 
detected,  with  reference  to  the  prevention  of  the  frequently  disastrous 
influences  of  latent  syphilis.  If,  however,  the  disease  be  contracted 
during  the  later  months  of  pregnancy,  the  treatment  may  consist  of 
palliative  measures  until  after  parturition,  since  no  harm  will  result 
from  the  maternal  syphilis  to  the  fetal  life.  Local  primary  or  second- 
ary disease  of  the  genitals  should  receive  appropriate  treatment,  in 
order  that  the  child  be  not  infected  during  delivery. 

Chronic  Nephritis. — There  are  few  subjects  about  which  so  much 
confusion  of  thought  exists  as  that  of  albuminuria  in  pregnancy. 
With  most  it  is  associated  in  the  mind  with  eclampsia,  and  yet 
*  Mewis,  loc.  cit.,  p.  42.  f  Frankel,  op.  cit.,  p.  53. 


ACCIDENTAL   COMPLICATIONS.  273 

eclampsia  in  chronic  nephritis  is  a  comparatively  rare  event.    (1 :40  ac- 
cording to  Fehling's  statistics;  2:70  according  to  those  of  Seyfert). 

It  is  desirable  to  differentiate,  therefore,  the  various  conditions  in 
which  albuminuria  develops  during  pregnancy.  Fehling's  *  researches 
in  this  direction  have  a  special  value. 

-  In  the  transitory  form  in  which  eclampsia  is  most  apt  to  occur, 
the  albuminuria  develops  in  the  later  months  of  pregnancy.  It  is  as- 
sociated with  an  abundance  of  hyaline  and  granular  casts,  and  has  a 
tendency  to  disappear  after  labor.  There  is,  moreover,  no  especial  dis- 
position for  the  albuminuria  to  return  in  later  pregnancies. 

In  a  second  group,  women  who  in  the  non- pregnant  state  are 
apparently  healthy,  or  who  exhibit  only  slight  traces  of  albumen  in  the 
urine,  develop  albuminuria  from  the  beginning  of  pregnancy.  In  these 
cases  the  casts  in  the  urine  are  scanty,  the  heart's  action  is  increased  in 
force,  there  is  sometimes  oedema,  and  occasionally  the  condition  is 
associated  with  hemorrhages.  In  most  cases  death  of  the  fwtus  occurs 
in  consequence  of  placental  changes.  The  amniotic  fluid  diminishes 
in  quantity,  the  uterus  is  arrested  in  its  development,  and  the  albu- 
minuria disappears  in  part,  or  in  its  entirety.  Characteristic  of  this 
form  is  its  tendency  to  recur  with  each  consecutive  pregnancy. 

In  still  another  group  of  cases  the  albuminuria  is  due  to  chronic 
Interstitial  or  parenchymatous  nephritis.  With  pregnancy  there  is 
usually  an  acute  exacerbation  of  the  symptoms.  Casts  and  albumen  be- 
come more  abundant,  oedema  develops,  albuminuric  retinitis  is  a  com- 
mon complication,  and  nasal  or  intracranial  haemorrhage  may  occur. 

The  causes  of  the  increased  trouble  are  attributed  to  reflex  contrac- 
tion of  the  arterioles  and  consecutive  ansemia  of  the  unaffected  portions 
of  the  kidney,  and  to  associated  venous  congestion  resulting  from 
cardiac  insufficiency.  As  regards  treatment,  Fehling  advises  to  ex- 
amine the  urine  frequently,  especially  if  oedema  is  present.  Slight 
traces  should  admonish  to  watchfulness.  If  the  amount  of  urine 
exceeds  one  per  cent,  woolen  underwear  should  be  worn ;  the  action  of 
the  skin  should  be  maintained  by  tepid  baths ;  the  diet  should  consist 
in  large  measure  of  milk,  and  alcohol  should  be  avoided.  In  severer 
cases  rest  in  bed,  hot  baths  (98°  to  107°),  and  warm  packs  often  give 
relief. 

If,  however,  there  are  headache,  nose-bleed,  heart  disturbance,  or 
if  no  improvement  in  the  number  of  casts  or  in  quantity  of  albumen 
results  from  treatment,  abortion  or  premature  labor  is  indicated. 

In  chronic  nephritis,  death  of  the  child  from  ])lacental  changes 
(white  infarctions,  according  to  Fehling)  is  so  common  that  considera- 
tions for  the  life  of  the  child  must  be  always  subsidiary  to  the  interests 
of  the  mother. 

*  Fehling,  Weitere  BeitrJige  znr  klinischon  Bedeutung  der  Nephritis  in  der 
Schwangerschaft,  Arch.  f.  Gynaek..  vol.,  xxxix,  ]>.  408. 
18 


274  THE  PATHOLOGY  OF   PREGNANCY. 

In  chronic  nephritis  it  is  not  desirable  that  the  kidneys  should  be 
subjected  to  the  hazards  of  a  renewal  of  pregnancy. 

Diabetes  in  Pregnancy. — Dr.  Mathews  Duncan  *  has  called  atten- 
tion to  the  very  serious  consequences  of  diabetes  complicating  preg- 
nancy and  the  puerperal  state.  But  few  cases  have  been  recorded. 
Diabetes  may  occur  during  pregnancy,  and  in  some  cases  during 
pregnancy  only.  It  may  cease  after  the  termination  of  pregnancy, 
and  may  not  return  in  pregnancy  after  its  cure.  Pregnancy  may  occur 
during  diabetes,  and  in  that  case  may  be  apparently  unaffected  in  its 
healthy  progress  by  the  disease. 

In  twenty-two  pregnancies,  occurring  in  fifteen  mothers,  four  termi- 
nated fatally.  In  several,  death  was  by  collapse  rather  than  by  coma. 
Hydramnios  was  frequent,  and  in  one  case  sugar  was  found  in  the 
fluid. 

In  seven  out  of  nineteen  pregnancies,  occurring  in  fifteen  mothers, 
the  child  died  in  pregnancy,  having  in  all  of  them  reached  u  viable 
age.  In  two  more  the  child  was  feeble  at  birth,  and  died  a  few  hours 
after.     In  one  case  the  child  was  diabetic. 

With  one  exception,  all  the  mothers  were  multij^arae. 

Chorea  in  Pregnancy. — Chorea,  which  is  a  rare  complication  of 
pregnancy,  affects  primipars  by  preference,  particularly  those  possess- 
ing an  hereditary  predisposition.  Barnes  f  was  able  to  collect  only 
fifty-six  and  Fehling  I  only  twelve  additional  cases  from  the  whole  do- 
main of  obstetrical  literature. 

Organic  cerebral  lesions  are  assumed  by  Spiegelberg*  as  established 
causes  of  the  disease.  In  regard  to  other  etiological  agencies  wide  di- 
versities of  opinion  prevail.  According  to  Goodell,||  the  choreic  move- 
ments are  of  reflex  nature,  and  are  referable  to  im])aired  nutrition  of 
the  central  nervous  system,  incident  to  the  hydraemia  of  pregnancy. 
The  association  of  chorea  and  organic  cardiac  disease  has  been  fre- 
quently observed,  and  the  discovery  in  certain  cases  of  fibrous  vege- 
tations upon  the  mitral  and  aortic  valves  accounts  for  the  assumption 
by  some  authors  of  embolism  as  a  cause  of  chorea.  Barnes'''  dis- 
countenances this  view,  and  calls  attention  to  the  probable  causative 
agency  of  myelitis.  Terror  and  other  intense  emotions  may  act  as 
exciting  causes  of  chorea. 

Choreic  movements  occurring  in  pregnancy  do  not  differ  from 
those  attending  the  disease  in  the  unimpregnated  state.  They  are 
usually  bilateral.  In  most  cases  the  muscular  contractions  manifest 
themselves  in  the  earlier  months  of  pregnancy,  and  continue  until 

*  Matthews  Duncan,  On  Puerperal  Diabetes,  Obstet.  Trans.,  vol.  xxiv,  p.  256. 
t  Barnes,  Trans,  of  the  Obstet.  Soc.  of  London,  x,  1869,  p.  147. 

X  Fehling,  Arch.  f.  Gynaek.,  vi.  1874,  p.  137. 

*  Spiegelberg,  Lehrb..  p.  2.5.5. 

I  GooDELL,  Am.  Jour,  of  Obstet.,  May,  1870,  p.  149. 
^  Barnes,  loc.  cit.,  p.  179. 


ACCIDENTAL  COMPLICATIONS.  375 

delivery  is  accomplished.  In  rare  instances  they  are  arrested  at  the 
beginning  of  parturition.  In  still  more  exceptional  cases  the  contrac- 
tions may  either  cease  before  delivery  or  persist  during  the ^0A^j!>a//7/?/i 
state.  Transitory  albuminuria  and  diabetes  mellitus  are  occasional 
unexplained  complications  of  chorea  gravidarum,  and  the  phosphates 
and  urates  of  the  urine  are  present  in  abnormal  abundance.  Abortion 
and  premature  delivery,  due  to  the  repeated  succussion  of  the  uterus, 
are  of  very  frequent  occurrence. 

Chorea  exerts  a  prejudicial  influence  upon  the  course  of  pregnancy,* 
having  interrupted  it  in  about  one  half  the  recorded  cases.  Death  of 
the  mother  resulted  in  seventeen  of  the  fifty-six  cases  collected  by 
Barnes. f  The  lethal  termination  was  usually  referable  to  the  ex- 
haustion consequent  upon  protracted  muscular  exertion,  or  to  hemi- 
plegia secondary  to  grave  cerebral  or  spinal  lesions.  The  life  of  the 
child  is  less  frequently  sacrificed,  but  it  is  itself  often  affected  with 
chorea. 

The  treatment  consists  in  the  administration  of  iron  and  quinine, 
and  the  lowering  of  the  reflex  excitability  by  the  prolonged  use  of  the 
bromide  of  potassium.  During  the  attack,  chloroform,  chloral,  and 
the  subcutaneous  injection  of  morphia  are  often  serviceable.  When 
palliative  remedies  prove  fruitless,  in  view  of  the  perilous  nature  of  the 
affection,  artificial  labor  or  even  abortion  is  indicated. 

Relaxation  of  the  Pelvic  Symphyses,  t — This  condition,  which  con- 
sists in  an  excess  of  the  ordinary  physiological  softening  at  the  jielvic 
articulations,  may  permit  of  such  a  degree  of  mobility  between  tlie 
pelvic  bones  as  to  effectually  hinder  locomotion.  This  is  usually  ac- 
companied by  pains  in  the  ligaments  of  the  joints  affected,  in  the 
thighs,  and  in  the  lumbar  region.  Its  existence  is  easily  recognized. 
Thus,  motion  at  the  symphysis  pubis  becomes  apparent  if,  with  the 
patient  in  an  upright  position,  she  be  made  to  throw  the  weight  of  the 
body  upon  each  leg  in  alternation,  while  the  accoucheur  holds  the  sym- 
physis between  the  thumb  and  two  fingers  placed  within  the  vagina. 
Motion  in  the  sacro-iliac  joint  is  perceived  by  seizing  the  crests  of  the 
ilium  and  getting  the  patient  to  move  forward.  In  the  recumbent 
posture  movements  at  either  the  pubic  or  sacro-iliac  joints  may  be 
recognized  by  means  of  the  vaginal  touch,  upon  extending  or  flexing 
the  femur. 

The  great  relief  afforded  to  all  the  symptoms  in  such  cases  by  means 
of  a  firm  binder  makes  it  most  desirable  that  the  possibility  of  its  oc- 
currence should  be  always  borne  in  mind  where  the  patient  walks  with 
difficulty  during  the  latter  months  of  pregnancy,  or  subsequent  to  the 

*  GooDELL,  Am.  Jour,  of  Obstet.,  vol.  viii,  p.  168. 
t  Barnes,  Trans,  of  the  Obstet.  Soc.  of  London,  x,  1869. 

i  Snelling,  On  Relaxation  of  the  Female  Pelvic  Symphyses,  American  Journal 
of  Obstetrics,  February,  1870;  Barker,  Puerperal  Diseases,  p.  192. 


276  THE  PATHOLOGY  OP  PREGNANCY. 

childbed  period.  The  first  case  I  witnessed  at  the  Bellevue  Hos- 
pital was  altogether  a  mystery  to  me,  until  the  nature  of  the  disabil- 
ity was  pointed  out  by  Professor  Barker.  The  patient  was  in  the 
last  month  of  pregnancy,  had  been  six  weeks  in  bed,  unable  to  move, 
though  apparently  otherwise  in  perfect  health.  A  rude  bandage, 
constructed  of  canvas  and  made  to  lace  in  front,  furnished  a  good 
support,  and  enabled  my  patient  to  stand  and  move  around  with- 
out inconvenience.  She  had,  at  the  end  of  gestation,  a  good  confine- 
ment, and  subsequently  recovered  without  a  trace  of  her  previous  diffi- 
culty. 

In  childbed  a  towel-binder  is  capable  of  rendering  good  service. 
During  pregnancy,  or  during  the  period  of  puerperal  convalescence, 
where  frequent  changes  of  the  bandage  are  not  necessary,  Martin's 
girdle,  consisting  of  a  solid  metal  ring  surrounding  the  whole  pelvis, 
has  been  strongly  recommended.  I  employ  a  pair  of  strong  breeches, 
furnished  me  by  Philip  Schmidt,  instrument-maker,  of  this  city,  which 
are  carefully  fitted  to  the  thighs  and  hips  of  the  patient,  and  are  made 
to  buckle  in  front  and  lace  behind.  The  apparatus  is  light,  comforta- 
ble, and  answers  every  requirement. 

Surgical  Operations  during  Pregnancy. — Massot*  concludes,  from 
the  observation  of  a  considerable  number  of  cases,  that  ordinary  surgi- 
cal operations  do  not  interfere  with  pregnancy  unless  they  materially 
and  permanently  disturb  the  uterine  circulation,  or  call  into  activity 
the  uterine  muscular  force  by  reflex  irritation.  Cohnstein  f  states  as 
the  result  of  his  researches,  that  after  operations  and  injuries  preg- 
nancy reaches  a  normal  termination  in  54-5  per  cent  of  all  cases.  In- 
terruption of  pregnancy  was  in  his  cases  determined — {a)  by  the 
period  of  pregnancy  when  the  operation  took  place,  occurring  more 
frequently  as  the  result  of  surgical  measures  resorted  to  in  the  third, 
fourth,  and  eighth  months  ;  {b)  upon  the  seat  of  the  operation,  result- 
ing, in  two  thirds  of  all  cases,  from  operations  upon  the  genito-urinary 
organs ;  (c)  upon  the  extent  of  the  wound  following  amputations,  ex- 
articulations,  and  ovariotomies  with  great  relative  frequency ;  (d)  upon 
the  number  of  children,  occurring  in  multiple  pregnancy  with  uniform 
regularity.  Age  seemed  to  exert  no  causative  influence.  Abortion  di- 
rectly results  under  these  circumstances  from  reflex  irritation,  or  from 
fetal  death  referable  to  hasmorrhage  or  to  septic  poisoning  on  the 
mother's  part.  The  prognosis,  so  far  as  the  mother  is  concerned,  de- 
pends upon  the  time  when  delivery  occurs.  The  mortality  ordinarily 
attending  delivery,  if  at  term,  is  insignificant ;  for  abortions  and  pre- 
mature deliveries  it  amounts,  according  to  Cohnstein,  to  thirty-three 

*  Massot,  Ueber  d.  Einfluss  trauraat.  Einwirk.  auf  d.  Verlauf  der  Schwanger- 
schaft,  Schmidt's  Jahrb.,  1874,  164,  p.  266. 

t  CoHNSTEix,  Ueber  chirurg.  Op.  bei  Schwangeren,  Volkmann's  Samml.  klin. 
Vortr.,  No.  59,  1873,  p.  493. 


ABNORMAL  CONDITIONS  OP  THE   UTERUS.  277 

per  cent.  The  most  frequent  causes  of  the  mother's  death  are  shock 
peritonitis,  septicemia,  haemorrhage,  and  oedema  pulraoualis.  In 
ninety  cases  of  minor  operations  upon  the  pelvic  organs  collected  by 
Professor  Mann,*  of  Buffalo,  there  were  twenty  abortions  and  four 
deaths.  They  included  the  removal  of  a  caruncle,  of  epitheliomata,  of 
condylomata,  and  of  polypi,  the  opening  of  cysts  and  abscesses,  the  dil- 
atation of  the  urethra  for  stone,  the  plastic  operations  upon  the  vulva, 
cervix,  and  vagina,  etc.  He  concludes  that  during  pregnancy  the 
union  of  denuded  surfaces  is  the  rule,  that  the  most  risky  operations 
are  those  upon  the  rectum,  and  that  vaginal  operations  are  apt  to  be  at- 
tended by  severe  hemorrhage,  though  not  otherwise  dangerous.  In 
view  of  the  manifest  danger  from  operations  of  any  magnitude,  it  may 
be  stated  as  a  general  law  that  surgical  measures  not  absolutely  indi- 
cated by  the  existence  of  pathological  conditions  liable  to  aggravation 
by  delayed  interference  should  be  postponed  until  after  confinement. 
Those  morbid  conditions,  however,  whose  development  is  hastened  by 
pregnancy,  which  threaten  the  existence  of  pregnancy,  or  whose  exist- 
ence offers  mechanical  obstacles  to  parturition,  must  be  early  subjected 
to  operative  interference.  This  remark  applies  with  special  force  to 
carcinomatous  growths  in  any  part  of  the  body  and  to  intrapelvic 
tumors. 

The  time  of  operation  should  not  coincide  with  the  menstrual 
epoch  of  pregnant  women,  as  abortion  is  more  likely  to  occur  at  that 
period.f  For  a  similar  reason  it  is  recommended  that  the  third, 
fourth,  and  eighth  months  should  be  avoided.  Massot  is  of  the  opin- 
ion I  that  anaesthetics,  when  employed  during  operations  on  pregnant 
women,  exert  rather  a  favorable  than  a  prejudicial  effect  upon  fetal 
life  by  diminishing  reflex  irritation. 

Abnormal  Conditions  of  the  Uterus. 

Double  Uterus. — Double  uterus  occurs  under  various  forms.  The 
uterus  and  cervix  may  be  double,  the  vagina  remaining  single.  The 
double  uterus  may  have  a  single  cervix  opening  into  an  undivided 
vagina.  The  uterus,  although  double,  may  have  a  single  cervix  open- 
ing into  a  double  vagina,  the  septum  beginning  at  the  os  internum ; 
or  uterus,  cervix,  and  vagina  nay  be  double  throughout. 

All  these  forms  permit  of  normal  utero-gestation  on  either  side  or 
on  both  sides  simultaneously,  provided  that  each  half  of  the  genital 
canal  be  sufficiently  developed.  If,  however,  the  dividing  septum  ex- 
tends quite  to  the  vaginal  entrance,  simultaneous  pregnancy  in  each 
horn  is  exceedingly  rare.* 

*  Manx,  Surgical  Operations  on  the  Pelvic  Organs  of  Pregnant  Women,  Gyna- 
cological  Trans.,  1883. 

f  Spiegelberg,  Lehrbuch  d.  Geburtsh.,  p.  268. 

t  Massot,  loc.  ciL,  p.  267.  *  Schroeder.  Lehrb.  d.  Geburtsh.,  p.  376. 


278  THE   PATHOLOGY    OF   PREGNANCY. 

If  pregnancy  occur  in  only  one  side  of  a  double  uterus,  a  decidua 
vera  is  developed  in  the  other  side,  and  expelled  at  the  end  of  preg- 
nancy. Double  uterus  is  less  readily  diagnosticated  during  pregnancy 
than' after  or  before  it,  but  is  usually  recognized  with  facility.  A 
double  vagina  is  not  necessarily  indicative  of  double  uterus,  but  if 
two  vaginae  are  found,  each  containing  a  cervix,  the  presence  of  double 
uterus  may  be  safely  assumed.  If  a  double  cervix  terminate  in  an  un- 
divided vagina,  the  uterus  may  or  may  not  be  double.  When  preg- 
nancy exists  in  only  one  horn  the  uterine  development  is  manifestly 
unilateral,  and  the  existence  of  an  unimpregnated  half  may  be  de- 
termined by  combined  manipulation  or  by  the  uterine  sound.  In 
cases  presenting  a  double  uterus  witli  a  single  cervix  and  vagina,  the 
diagnosis  rests  chiefly  upon  unilateral  uterine  development  and  de- 
pression of  the  fundus  and  body  corresponding  to  the  septum.  The 
form  of  a  double  uterus  is  most  plainly  manifest  during  the  contrac- 
tions accompanying  and  succeeding  parturition.*  It  is  still  undecided 
whether  double  uterus  be  a  cause  of  abortion  and  of  premature  de- 
livery. Ordinarily,  however,  the  symptoms  and  course  of  pregnancy 
are  unaffected  by  this  malformation.  The  complete  functional  inde- 
pendence of  the  two  segments  is  demonstrated  by  the  fact  that  in 
twin  pregnancies  parturition  is  frequently  not  simultaneously  accom- 
plished by  them.  In  the  case  of  unilateral  pregnancy,  the  ratio  of 
head  to  breech  presentations  is,  according  to  Schatz,  as  twenty-one  to 
two.  Tedious  labor  may  result  in  cases  of  double  uterus  from  uterine 
atony,  referable  either  to  imperfect  muscular  development  of  the  preg- 
nant horn,  to  its  deviation  from  the  normal  pelvic  axis,  or  to  obstruc- 
tion produced  by  the  unimpregnated  horn.  Post-purtuni  haemorrhage 
may  result  from  uterine  atony  or  from  attachment  of  the  placenta  to 
the  septum,  whose  imperfect  development  prevents  its  firm  and  thor- 
ough contraction. 

Anteversion  and  Anteflexion. — The  normal  anteversion  of  the  un- 
impregnated uterus  is  exaggerated  by  the  increased  weight  of  the 
gravid  uterine  body,  but  this  deviation  is  usually  rectified  by  the  grad- 
ual development  and  upward  movement  of  the  uterus.  In  exceptional 
cases  the  anteversion  persists  after  the  fourth  mouth,  and  produces 
vesical  tenesmus,  dysuria,  or  incontinence.  No  evidences  of  uterine 
incarceration  are,  however,  observed,  and  the  comparatively  trivial 
symptoms  are  relieved  by  regulating  defecation,  replacing  the  fundus, 
causing  the  patient  to  assume  the  dorsal  decubitus,  or  by  adjusting  an 
appropriate  pessary. 

In  the  later  stages  of  utero-gestation  anteversion  combined  with 
anteflexion  may  again  occur,  and  produce  the  deformity  known  as 
pendulous  abdomen.     It  is  then  chiefly  due  to  the  inadequate  sup- 

*  Schatz,  Mitth.  aus  d.  Leipz.  Geb.-Klinik  u.  Polyklinik.  Arch.  f.  Gynaek.,  ii, 
1871,  p.  297. 


ABNORMAL  CONDITIONS  OF  THE  UTERUS.       2^9 

port  afforded  to  the  uterus  by  the  abdominal  parietes.  The  failure  of 
their  sustaining  power  is  referable  to  their  relaxation— which  is  most 
marked  in  multiparae— to  separation  of  the  recti  muscles,  or  to  the 
yielding  of  old  cicatrices  produced  by  operations  or  injuries.  The  dis- 
placement is  also  favored  by  lordosis  of  the  lumbar  vertebrae  and  by 
contracted  pelvis,  which  prevent  the  normal  descent  of  the  uterus.  In 
extreme  eases  of  pendulous  abdomen,  the  uterus,  having  separated  the 
recti,  descends,  covered  by  fascia  and  skin,  almost  or  quite  to  the 
knees,  and  seriously  interferes  with  locomotion.  Its  pressure  also  pro- 
duces ffidema  of  the  abdominal  wall,  vesical  tenesmus,  and  pain  in  the 
distended  cutaneous  tissues.  These  symptoms  are  relieved  by  repo- 
sition of  the  uterus  and  by  the  application  of  a  suitable  abdominal 
bandage. 

Retroversion. — Retroversion,  a  comparatively  infrequent  form  of 
displacement  in  the  unimpregnated  uterus,  usually  rectifies  itself  dur- 
ing the  earlier  months  of  pregnancy.  Should  spontaneous  restitution 
not  occur,  the  fundus  being  detained  below  the  promontory  until  after 
the  third  month,  the  cervix  bends  upon  itself  at  an  acute  angle,  and 
the  retroversion  is  transformed  into  a  retroflexion. 

Retroflexion. — Retroflexion  occurs  infrequently  in  women  who  have 
not  borne  children,  but  often  renders  sterile  those  who  are  thus  affect- 
ed. It  is  one  of  the  most  common  uterine  displacements  in  women 
who  have  borne  children,  though  it  does  not  in  their  case,  ordinarily 
prevent  conception.  AA'hen  conception  occurs  in  a  retroflexed  uterus, 
the  latter  usually  rises  from  the  pelvis,  and  assumes  a  position  of  ante- 
version  at  the  fourth  month.  In  many  cases,  however,  the  displace- 
ment produces  congestion  of  the  uterine  mucous  membrane,  metritis, 
and  abortion.  In  still  other  cases  the  fundus  does  not  ascend  above 
the  promontory  at  the  usual  time,  and  either  the  sym})toms  of  retro- 
flexion with  incarceration  are  slowly  developed,  or  that  form  of  retro- 
flexion known  as  partial  retroflexion,  or  retroflexion  in  the  second  half 
of  pregnancy,  occurs.  This  consists  in  the  division  of  the  uterine 
cavity  into  an  anterior  and  a  posterior  diverticulum  or  iiouch.  The 
anterior  diverticulum  is  produced  by  the  more  rapid  upward  develop- 
ment of  the  anterior  uterine  wall,  Avhicli  is  subjected  to  comparatively 
slight  pressure  and  contains  the  larger  part  of  the  foetus.  The  pos- 
terior uterine  wall  enters  predominantly  into  the  formation  of  the 
posterior  diverticulum,  and  usually  contains  the  fetal  head.  This 
peculiar  form  of  uterine  displacement  may  be  spontaneously  rectified 
during  pregnancy,  or  may  persist  until  delivery,  producing  no  impor- 
tant symptoms  except  vesical  and  rectal  tenesmus,  with  dysuriji  and 
painful  defecation.  In  the  latter  case  it  materially  interferes  with  par- 
turition, inasmuch  as  the  cervix,  which  is  displaced  upward  and  for- 
ward behind  the  svmphvsis,  is  not  situated  in  the  pelvic  axis,  and  the 
posterior  diverticulum '  is  forced  by  the  uterine  contractions  against 


280    *      THE  PATHOLOGY  OF  PREGNANCY. 

the  perinaeum  and  posterior  vaginal  wall.  Even  at  this  stage  Nature 
may  restore  the  uterus  to  its  normal  position ;  but,  in  default  of  spon- 
taneous restitution,  it  must  be  replaced  by  forcing  up  the  posterior 
diverticulum  with  the  hand  introduced  into  the  rectum,  while  the  an- 
terior pouch  is  displaced  downward  by  pressure  upon  the  abdomen  and 
by  traction  applied  to  the  cervix ;  or,  where  version  is  practicable,  by 
bringing  down  the  breech,  room  may  be  made  for  the  release  of  the 
imprisoned  head. 

Retroflexion  of  the  Gravid  Uterus,  with  Incarceration.— Although 
this  form  of  retroflexion  is  usually  developed  in  the  gradual  manner 
above  described,  it  may,  in  rare  instances,  be  rapidly  produced  by  sud- 
den abdominal  compression  or  concussion. 

The  symptoms,  which  are  in  either  case  essentially  the  same,  differ 
chiefly  in  the  varying  rapidity  of  their  development,  and  result  from 
the  pressure  of  the  displaced  uterus  upon  the  intrapelvic  viscera  and 
tissues,  They  embrace  dysuria,  eventuating  sometimes  in  complete  re- 
tention of  urine  from  urethral  compression,  vesical  tenesmus,  incon- 
tinence of  urine,  painful  defecation,  constipation  or  obstipation,  vio- 
lent sacral  and  lumbar  pains  which  radiate  into  the  thighs,  and  in 
grave  cases  emesis,  with  all  the  other  symptoms  of  ileus  Abortion, 
followed  by  spontaneous  restitution  and  recovery,  may  occur  even  at 
this  stage.  Should  incarceration,  however,  persist,  violent  metritis, 
parametritis,  and  peritonitis  may  lead  to  a  fatal  issue.  In  rare  cases, 
gangrene  of  the  uterus  or  vagina  may  be  induced.  A  lethal  termina- 
tion may  also  indirectly  result  from  pathological  processes  in  the  blad- 
der occasioned  by  retained  and  decomposing  urine.  These  morbid 
processes  consist  in  cystitis,  sometimes  complicated  by  diphtheritic  and 
gangrenous  inflammation  of  the  mucous  membrane  and  of  the  deeper 
vesical  tissues,  which  may  lead  to  septicaemia  or  to  rupture  of  the  blad- 
der. Death  may,  moreover,  result  from  passive  renal  congestion  and 
ursemia. 

The  diagnosis  of  uterine  retroflexion  with  incarceration  is  based 
upon  the  foregoing  clinical  history  ;  the  fluctuating  abdominal  tumor, 
from  which  large  quantities  of  urine  may  be  obtained  by  the  catheter 
or  by  puncture ;  the  oedema  of  the  vulva  ;  the  presence  in  Douglas's 
cul-de-sac  of  a  tumor  presenting  the  characteristic  consistence  of  uter- 
ine tissue  ;  the  position  of  the  cervix  and  meatus  urinarius  behind  the 
symphysis ;  and  the  distention  of  the  perinaeum  by  the  fundus  uteri. 

The  distinction  between  an  incarcerated  uterus  and  an  extra-uterine 
pregnancy  is  sometimes  difficult,  necessitating  a  thorough  bimanual 
examination,  aided,  in  cases  of  abdominal  tenderness,  by  the  employ- 
ment of  an  anaesthetic. 

The  replacement  of  the  uterus,  which,  of  course,  is  the  objective 
point  of  treatment,  should  in  all  cases  be  preceded  by  the  evacuation 
of  the  bladder.     This  is  usually  accomplished  without  much  trouble 


ABNORMAL  CONDITIONS  OF  THE   UTERUS.  281 

by  means  of  a  sharply  curved  male  catheter,  and  by  remembering  that 
the  urethra  is  ordinarily  deflected  somewhat  to  one  side.  Cohnstein 
states  that  the  introduction  of  the  catheter  is  facilitated  by  seizing  the 
posterior  lip  or  the  vaginal  portion  with  volsella  forceps,  and  diminish- 
ing the  pressure  on  the  urethra  by  tractions  made  in  a  backward  di- 
rection. Veit,*  in  an  experience  of  from  seventy  to  eighty  cases,  found 
catheterization  always  practicable.  Where  intelligent  effort  is  at- 
tended by  failure,  puncture  is  allowable.  To  this  end  an  aspirator 
needle — which,  however,  should  not  be  of  too  small  caliber — should  be 
passed  through  the  abdominal  walls  at  a  point  about  three  inches  above 
the  symphysis.  In  practice  this  operation  has  thus  far  proved  devoid 
of  danger,  though  the  possible  risk  from  infiltration  of  urine  should 
act  as  a  check  to  its  rash  employment. 

After  emptying  the  bladder  spontaneous  reposition  may  take 
place.  If  this  does  not  speedily  occur,  the  patient  should  be  put  in  the 
knee-elbow  position,  and  steady  pressure  should  be  made  with  two  or 
four  fingers  upon  the  fundus,  through  the  vagina.  With  a  little  pa- 
tience this  method  rarely  fails.  E.  Martin  f  reports  sixteen  cases,  in 
four  of  which  spontaneous  reposition  followed  the  evacuation  of  the 
bladder,  and  in  eleven  reposition  was  accomplished  in  the  knee  elbow 
position.  In  my  own  practice  the  latter  method  has  so  far  invariably 
proved  successful.  If  anaesthesia  is  -required,  the  replacement  of  the 
uterus  should  be  attempted  with  the  patient  in  the  Sims  latero-prone 
position.  Pressure  upon  the  fundus  should  be  exerted  by  four  fingers 
introduced  into  the  vagina  or  rectum.  Barnes  J  recommends  tilting 
the  fundus  to  one  side,  so  as  to  disengage  it  from  the  projection  of  the 
promontory.  It  may  happen  that  the  first  attempt  may  be  only  par- 
tially successful,  while  a  renewal  of  the  manipulation  after  twelve  to 
twenty-four  hours  may  lead  to  complete  reduction  (Veit). 

In  exceptional  cases  the  replacement  of  the  uterus  may  be  prevent- 
ed by  inflammatory  adhesions,  or  by  the  secondary  swelling  of  the  dis- 
placed organ.  The  induction  of  abortion  then  becomes  imperative, 
either  by  the  ordinary  methods  or  by  puncture  of  the  uterine  walls. 

The  introduction  of  a  uterine  sound  or  a  flexible  catheter  is  rarely 
practicable.  In  a  case  reported  by  P.  Miiller,*  where  the  retroversion 
was  complete,  with  the  fundus  upon  the  perineum  and  the  cervix 
looking  directly  upward,  Muller  resorted  to  the  following  ingenious 
expedient :  He  cut  off  the  end  of  a  male  silver  catheter,  and  then  bent 
the  extremity  into  a  hook.     Having  succeeded   in  passing  the  latter 

*  Veit,  Ueber  die  Retroflexion  der   Gebarmutter  in  den  spateren  Scbwanger- 
schaftsmonaten,  Volkmann's  Samml.  klin.  Vortr.,  No.  170,  p,  i;j()3. 

t  E.  Martin,  Riickwartsiieigung  der  schwangeren  GebJirrautter,  Ztschr.  f.  Ge- 
burtsh.  und  Frauenkrankheiten.  vol.  i,  p.  1. 

I  Barnes,  Obstetric  Operations,  third  American  edition,  p.  276. 

»  P.  MuLLEB,  Zur  Therapie  der  Retroversio  Uteri  gravidi,  Beitr.  zur  Geburtsh^ 
Bd.  iii,  p.  67. 


282  THE  PATHOLOGY  OF  PREGNANCY. 

into  the  cervix,  lie  introduced  a  piece  of  catgut  through  the  tube  be- 
tween the  membranes  and  the  uterus.  After  twelve  hours,  during 
which  the  catgut  was  left  in  situ,  the  foetus  was  expelled.  If  catheter- 
ization can  not  be  accomplished  by  either  of  the  foregoing  methods, 
puncture  of  the  uterus  with  a  fine  trocar,  and  with  antiseptic  precau- 
tions, has  proved  a  tolerably  safe  procedure,  and,  by  the  withdrawal 
of  a  portion  of  the  amniotic  fluid,  a  certain  means  of  provoking  abor- 
tion. 

Prolapse  of  the  Pre^ant  Uterus. — In  rare  instances  the  normal 
pregnant  uterus  becomes  prolapsed  during  the  early  months  through 
mechanical  violence,  and  its  sudden  displacement  may  lead  to  abortion 
through  uterine  congestion  and  haemorrhage.  Ordinarily,  however, 
procidentia  uteri  is  only  observed  during  pregnancy  when  it  has 
antedated  conception,  and  it  is  most  frequent  in  multiparae.  A  slight 
prolapse  disappears  temporarily  with  the  ascent  of  the  uterus.  A  well- 
marked  procidentia,  however,  as  a  result  of  which  a  part  or  the  whole 
of  the  uterus  has  been  extruded  from  the  vagina,  is  often  attended  by 
symptoms  of  incarceration  terminating  in  abortion.  There  is  no 
recorded  instance  of  procidentia  in  which  pregnancy  persisted  until 
the  time  of  normal  delivery  in  a  uterus  lying  Avholly  without  the 
vagina.  Procidentia  uteri  is  simulated  by  hypertrophy  either  of  the 
supravaginal  or  of  the  infravaginal  portion  of  the  cervix.  This  patho- 
logical condition  is  unattended  by  grave  results,  unless  it  lead  to  rigid- 
ity of  the  OS  uteri,  tedious  delivery,  and  uterine  inertia.  If  excessively 
developed,  however,  the  portio  vaginalis  may  be  transformed  into  a 
pulpy,  polyp-like  mass,  which  by  its  constant  friction  and  irritation 
produces  abortion.  It  should  not  be  mistaken  for  prolapse  of  the 
uterus,  as  efforts  at  reposition  may  produce  irritation  sufficiently  severe 
to  induce  premature  delivery.  Amputation  of  the  hypertrophied  cer- 
vix performed  during  the  third  month  does  not  necessarily  disturb 
pregnancy,  and  is  indicated  in  aggravated  cases,  because  of  the  possi- 
ble prejudicial  influence  of  cervical  hypertrophy,  unmodified  by  treat- 
ment, upon  utero-gestation  and  parturition. 

When  prolapse,  even  of  slight  extent,  exists  in  a  pregnant  uterus, 
the  normal  ascent  of  the  organ  should  be  encouraged  by  the  avoidance 
of  exertion  and  by  careful  regulation  of  defecation  and  micturition. 
In  more  pronounced  cases  the  uterus  must  be  replaced,  and  sustained 
by  a  suitable  tampon  Spiegelberg  *  advises  the  use  of  a  cotton  tampon 
soaked  in  glycerin  and  held  in  position  by  a  perineal  bandage,  aiui 
renewed  at  short  intervals.  Caution  is  necessary  in  the  reduction  of 
the  uterus,  lest  the  fundus  be  caught  beneath  the  symphysis  and  the 
procidentia  converted  into  a  retroflexion.  When  incarceration  has  oc- 
curred and  the  parts  are  much  swollen,  their  volume  may  be  reduced 
by  scarification,  after  which  reposition  must  be  attempted.  Should  it 
*  Spiegelberg,  Geburtshiilfe,  p.  278. 


ABNOliMAL  CONDITIONS  OF  TUE   UTERUS.  2>(3 

fail,  abortion  should   be  induced  before  the  incarceration  has  irrepa- 
rably compromised  the  vitality  of  the  pelvic  tissues. 

Prolapse  of  the  Vagina.— A  slight  degree  of  vaginal  prolapse  occurs 
more  frequently  in  pregnant  women  than  does  uterine  prolapse.  Cases 
of  more  complete  prolapse  of  the  vagina  are,  however,  almost  invari- 
ably attended  with  procidentia  uteri.  The  anterior  vaginal  wall  is 
usually  alone  involved  in  the  prolapse,  although  the  posterior  wall 
may  descend  alone,  or  both  walls  become  simultaneously  prolapsed. 
This  displacement  produces  traction  upon  the  bladder  and  rectum, 
resulting  in  irritation  of  these  organs  and  of  the  vulva.  During  i)ar- 
turition,  moreover,  the  prolapsed  vagina  offers  an  impediment  to 
delivery,  and  may  therefore  be  subjected  to  an  amount  of  pressure  in- 
compatible with  the  maintenance  of  its  vitality.  The  treatment  con- 
sists in  producing  regular  alvine  evacuations,  and  in  sustaining  the 
vagina  with  cotton  tampons  and  a  perineal  band,  or  with  the  latter 
alone.  During  labor,  persistent  efforts  at  reposition  of  the  prolapsed 
vagina  must  be  made  between  the  pains.  Should  these  attempts  prove 
effectual,  the  vagina  must  be-  sustained  in  proper  position  until  the 
descent  of  the  head  has  occurred.  If  reposition  be  impossible,  the 
forceps  must  be  resorted  to  in  order  to  prevent  the  disastrous  results 
of  excessive  pressure  on  the  vaginal  tissues,  and  traction  must  be  so 
applied  as  to  avoid  injury  of  the  anterior  vaginal  wall. 

Hernias  of  the  Pregnant  Uterus.— Although  hernias  of  the  uniui- 
pregnated  uterus  are  very  rare,  they  still  occur  much  more  frequently 
than  those  of  the  gravid  uterus.  The  most  frequent  forms  under 
which  they  present  themselves  are  the  umbilical  and  the  ventral. 
Femoral  and  inguinal  uterine  hernias,  as  well  as  hernias  through  the 
foramen  ovale  and  the  great  sacro-sciatic  foramen,  also  occur.  The  sac 
of  a  ventral  hernia  is  often  formed  by  the  yielding  and  dilatation  of 
extensive  cicatrices  in  the  abdominal  wall,  such  as  result  from  ovari- 
otomies and  gastrotomies,  or  by  the  separation  of  the  recti  muscles. 

Femoral  and  inguinal  uterine  hernias  are  either  congenital  or  are 
produced  by  ovarian  or  omental  hernias,  between  which  and  the  uterus 
adhesions  exist.  Pregnancy  has  been  observed  to  occur  most  frequently 
in  inguinal  uterine  hernias,  next  in  umbilical,  and  least  frequently  in 
femoral  hernias.*  It  has  never  been  discovered  in  a  uterus  which  had 
escaped  through  the  foramen  ovale  or  the  greater  sacro-sciatic  foramen. 
Pregnancy  occurring  in  inguinal  or  femoral  uterine  hernias  is  uni- 
formly terminated  by  abortion  or  by  premature  delivery.  The  diag- 
nosis is  readily  made  if  due  regard  be  paid  to  the  absence  of  the  uterus 
from  its  natural  situation,  to  the  shape  and  consistence  of  the  hernial 
tumor,  to  the  physical  signs  furnished  by  auscultation  and  percussion 
over  it,  and  to  the  displacement  of  the  vagina  toward  the  site  of  the 
hernia. 

*  SPIE(!KLBKR(i.  Cifburtsli..  p.  '280. 


284  THE  PATHOLOGY  OF  PREGNANCY. 

When  the  hernia  is  recognized  at  an  early  date,  the  uterus  must,  if 
possible,  be  restored  to  its  normal  position,  and  there  retained  by  an 
appropriate  truss.  Should  attempts  at  reposition  be  unsuccessful, 
artificial  abortion  should  be  induced,  as  it  will  otherwise  occur  spon- 
taneously at  a  later  date,  and  under  less  favorable  conditions.  When 
the  product  of  conception  has  already  attained  a  large  size,  reposition 
and  delivery,  whether  spontaneous  or  artificial,  are  rarely  accomplished 
unless  the  constricting  hernial  ring  be  previously  divided.  Even  the 
latter  procedure  may  prove  ineffectual,  in  which  case  hysterotomy  is 
the  last  resort. 


CHAPTER   XV. 

DISEASES  OF  THE  DECIDUA.— DISEASES  OF  THE  OVUM. 

Endometritis  decidua :  1.  Chronica;  2.  Tuberosa;  3.  Catarrhalis. — Anomalies  of 
the  placenta. — Anomalies  of  form ;  of  position  ;  of  development ;  of  circula- 
tion.— Placentitis. — Degenerations. — Syphilis. — Anomalies  of  the  amnion  and 
of  the  amniotic  fluid. — Hydramnion. — Deficiency  of  amniotic  fluid. — Anomalies 
of  the  umbilical  cord :  torsion  ;  knots ;  hernias ;  coiling  of  the  cord  ;  cysts ; 
stenoses  of  vessels ;  marginal  implantations. — Hydatidiform  mole. 

Endometritis  decidua. — The  normal  congestion  of  the  uterine  mu- 
cous membrane  attendant  upon  conception,  and  resulting  in  the  forma- 
tion of  the  decidua,  may,  under  the  irritating  influence  of  various 
exciting  causes,  develop  into  endometritis.  The  inflammation  may  be 
either  acute  in  character,  as  is  often  tlie  case  in  cholera  Asiatica  and 
other  infectious  diseases,*  or  may  pursue  a  chronic  course,  presenting 
itself  in  the  three  distinct  forms  about  to  be  considered  : 

L  Endometritis  decidua  chronica  diffusa. — The  causes  of  this  form 
of  endometritis  are  not  usually  readily  discoverable.  It  is  believed  to 
be  sometimes  developed  from  an  endometritis  antedating  conception. 
It  is  also  referred  to  syphilitic  infection,!  to  excessive  physical  exer- 
tion,J  and  to  secondary  inflammation  resulting  from  the  death  of  the 
foetus  and  its  retention  in  the  uterine  cavity.** 

The  anatomical  changes  characteristic  of  this  form  of  endometritis 
consist  essentially  in  thickening  and  induration  of  the  decidua,  due 
to  a  more  or  less  diffuse  development  of  new  connective  tissue,  and  to 
proliferation  of  the  decidual  cells.  Cysts  have  been  observed  in  the 
hypertrophied   decidua   by   Hegar  and   Maier.||     Kaschewarowa  dis- 

*  Slavjanksy,  Arch.  f.  Gynaek.,  iv,  p.  285. 
t  Prankel,  Arch.  f.  Gynaek.,  v,  1873,  p.  53. 

X  Kaschewarowa,  Virchow's  Arch.,  1868,  vol.  xliv,  p.  113. 

*  ScHROEDER,  Geburtsh.,  sixth  edition,  p.  392. 
Ij  Spiegelberg,  Geburtsh.,  p.  301. 


DISEASES  OP  THE   DECIDUA.  285 

covered  newly  developed  and  liypertrophied  involuntary  muscular 
fibers  in  the  substance  of  the  decidua.*  Extravasations  into  the  hyper- 
trophied  decidual  tissue  are  of  frequent  occurrence.!  The  decidua 
vera  or  the  decidua  reflexa  may  be  separately  or  Jointly  involved  in 
these  pathological  processes,  and  may  be  affected  throughout  a  part 
or  the  whole  of  their  extent.  When  the  hyperplasia  of  the  mucous 
membrane  is  developed  in  the  later  months  of  utero-gestation,  pursues 
a  notably  chronic  course,  is  limited  in  extent,  or  does  not  .involve  the 
placental  decidua,  pregnancy  may  proceed  to  a  normal  termination. 
When,  however,  the  endometritis  appears  early,  assumes  an  acute  or 
hjemorrhagic  type,  is  attended  by  partial  separation  of  the  decidua,  or 
involves  the  placental  decidua,  it  frequently  induces  abortion  or  i)re- 
mature  delivery,  either  by  causing  the  deatla  of  the  foetus  through  in- 
terference with  its  nutrition  J  or  by  exciting  reflex  uterine  contrac- 
tions. Parturition  may,  in  either  case,  be  protracted  by  the  slow 
separation  of  the  decidua,  between  which  and  the  deeper  uterine  tis- 
sues adhesions  have  been  formed  by  the  newly  developed  connective 
tissue  and  muscular  fibers.  If  the  placental  decidua  be  involved  in 
the  morbid  process,  the  placenta  may  be  separated  with  difficulty,  and 
its  slow  expulsion  be  attended  by  copious  haemorrhages.  Another  con- 
sequence of  the  hyperplasia  of  the  decidua  in  the  later  months  of 
pregnancy,  according  to  Kaltenbach,*  consists  in  the  non-separation 
of  the  decidua  vera  at  the  time  of  parturition.  The  thickened  mem- 
brane is  either  rapidly  detached  after  childbirth,  forming  a  sac  to 
which  blood  coagula  adhere,  and  which  in  turn  become  the  occasion 
of  haemorrhage,  or  it  is  slowly  eliminated,  giving  rise  to  a  putrid 
discharge,  and  furnishing  materials  for  auto-infection.  He  advises, 
therefore,  in  cases  of  syphilis  in  either  parent,  that  a  careful  examina- 
tion be  made  of  the  membranes  at  childbirth,  and,  if  no  traces  of  the 
decidua  are  to  be  found  upon  their  surface,  to  introduce  the  hand  into 
the  uterus,  and  to  remove  retained  portions ;  or,  should  this  not  be  done, 
to  promote  their  expulsion  by  ergo  tin,  and  to  employ  prophylactic 
antiseptic  injections. 

II.  Endometritis  decidua  tuberosa  et  polyposa.— The  etiology  of 
this  variety  of  decidual  inflammation  is  involved  in  obscurity.  Syph- 
ilis was  regarded  as  a  causative  agent  by  Virchow,  who  first  described 
the  degenerative  changes  under  consideration,!  and  pre-existent  endo- 
metritis is  also  supposed  to  occupy  a  causative  relation  to  them.  Gus- 
serow^  suggests  that  conception  occurring  soon   after  delivery  may 

*  Kaschewarowa,  he.  cit.,  p.  111. 

f  EiGENBROD  und  Hegab,  Monatsschr.  f.  Geburtsk..  vol.  xxii,  1863.  {>.  161. 
I  Klebs.  Monatsschr.  f.  Geburtsk.,  1806,  vol.  xxvii.  p.  402. 

*  Kaltexbach,  Diffuse  Flyperplasic  der  De<'idiia  am  Ende  der  GraviditaU 
Zeitschr.  fiir  Gebiirtsh.  und  Gynnek.,  vol.  ii,  p.  225. 

I  Ahlfeld,  Arch.  f.  Gynaek.,  vol,  x,  1876,  p.  173, 

^  GussEROw,  Monatsschr,  f.  Gynaek.,  vol,  xxvii.  1866,  p.  383. 


286  THE  PATHOLOGY  OP  PREGNANCY. 

excite  the  recently  formed  vascular  uterine  nuieous  membrane  to  ab- 
normal proliferative  processes.  It  is  doubtful  whether  the  latter  are 
ever  secondary  to  irritation  produced  by  the  death  of  the  foetus.*  In 
Ahlfeld's  cases  the  inflammation  was  apparently  idiopathic. 

The  pathological  processes  peculiar  to  this  variety  of  endometritis 
are  usually  observed  in  the  decidua  vera  alone,  and  manifest  a  jirefer- 
ence  for  those  portions  of  the  decidua  corresponding  to  the  anterior 
and  posterior  uterine  surfaces.  In  some  cases,  characterized  by  absence 
of  the  decidua  vera,  the  decidua  reflexa  is  found  involved  in  the  mor- 
bid changes.  The  latter  consist  in  marked  thickening  of  the  entire 
decidua  referable  to  proliferation  of  the  interstitial  connective  tissue 
and  to  extensive  hypertrophy  of  the  decidual  cells,  which  are  provided 
with  nuclei  of  enormous  size.  Occasional  free  nuclei  occur. f  The 
uterine  surface  of  the  decidua  is  rough  and  covered  with  coagulated 
blood,  while  the  entire  mucous  membrane  is  exceedingly  vascular. 
Upon  that  surface  of  the  decidua  which  is  directed  toward  the  ovum 
are  situated  large  excrescences  or  elevations,  the  prevailing  shape  of 
which  is  polypoid.  They  may,  however,  appear  in  the  form  of  nod- 
ules, of  cones,  or  of  boss-like  projections  provided  with  a  broad,  non- 
pedunculated  base.  Their  height  is  from  one  quarter  to  one  half  an 
inch,  and  their  surface  is  smooth,  very  vascular,  and  devoid  of  uterine 
follicles.  The  latter  are,  however,  plainly  visible  on  the  mucous  mem- 
brane intervening  between  the  polypoid  outgrowths,  but  they  are  com- 
pressed and  their  orifices  constricted  or  obliterated  by  the  pressure 
of  Avhitish,  contracting  bands  of  newly  developed  connective  tissue. 
Similar  fibrous  bands  surround  the  blood-vessels.  On  section,  the 
larger  prominences  sometimes  appear  permeated  with  coagulated  blood, 
and  narrow,  cord -like  bands  of  hypertrophied  decidual  tissue  occasion- 
ally form  bridge-like  connections  between  neighboring  polvpi.  The 
uterine  follicles  are  in  some  cases  filled  with  blood-clots.  The  epi- 
thelium is  often  absent  from  the  uterine  surface  of  the  decidua  except 
around  the  orifices  of  the  follicular  glands,J  and  the  deeper  decidual 
tissues  contain  large  numbers  of  lymphoid  cells.  The  cells  of  the 
decidua  reflexa  frequently  undergo  fatty  degeneration.  The  placental 
villi  may  show  hypertrophy  of  their  club-shaped  ends,  or  be  the  seat 
of  myxomatous  growths,  in  which  case  their  cells  are  granular  and 
cloudy.  The  fa?tus  is  generally  dead  and  partially  disintegrated. 
This  form  of  endometritis  decidua  is  consequently  usually  accom- 
panied by  abortion,  which  occurs  predominantly  at  an  early  stage  of 
pregnancy. 

III.  Endometritis  decidua  catarrhalis.— Hydrorrlioea  gravidarum.— 
This  form  of  uterine  inflammation  is  less  intense  than  the  two  varie- 

*  ScHROEDER,  Geburtsh.,  sixth  edition,  p.  393. 

f  GussERow,  loc.  cU.,  p.  322. 

X  Hegar,  Monatsschr.  f.  Geburtsk.,  vol.  xxii,  1863,  pp.  300,  429. 


DISEASES  OF  THE  OVUM.  287 

ties  just  described,  affects  pluriparae  more  frequently  than  primiparae, 
and  seems  to  stand  in  etiological  relations  with  hydrsemia.  The 
pathological  processes  involved  in  the  disease  are  vascularity,  hyperse- 
mia,  and  hypertrophy  of  the  interstitial  connective  tissue  and  of  the 
glandular  elements  of  the  decidua.  The  inflammation  involves  the 
decidua  vera  by  preference,  but  may  simultaneously  affect  the  de- 
cidua refiexa.  The  most  striking  symptomatic  occurrence  is  due  to 
the  glandular  hypertrophy,  and  consists  in  the  escape  from  the  uterine 
cavity  of  a  thin,  watery,  muco-purulent  or  sero-sanguinolent  liquid, 
which  resembles  the  amniotic  fluid  both  in  color  and  in  odor.  Pro- 
vided that  free  exit  be  afforded  to  the  secretion,  its  discharge  is  affected 
gradually  and  in  small  quantities.  Should,  however,  obstacles  to  its 
continuous  evacuation  be  encountered,  either  in  the  usual  adhesions 
between  the  decidua  vera  and  reflexa  or  in  impenetrability  of  the  os 
internum,  the  secretion,  having  accumulated  between  the  decidua  and 
the  chorion,  forces  a  passage  through  the  decidua  reflexa  and  is  dis- 
charged in  considerable  quantities.  In  some  cases  even  a  pound  or 
more  of  the  liquid  is  thus  suddenly  evacuated.  Small  quantities  of 
the  secretion  are  often  observed  as  early  as  the  third  month.  The 
more  abundant  discharges  occur  only  in  the  later  periods  of  pregnancy, 
and  are  often  attended  by  slight  uterine  contractions,  which  may,  in 
exceptional  cases,  become  so  severe  as  to  induce  abortion  or  premature 
delivery. 

The  diagnosis  involves  differentiations  between  a  discharge  emanat- 
ing from  the  hypertrophied  decidual  glands  and  the  ante-'partwii  es- 
cape of  a  fluid  which  sometimes  accumulates  between  the  amnion  and 
chorion.  The  latter  discharge,  the  quantity  of  which  may  be  so  large 
as  to  stimulate  hydramnion,  differs  from  that  of  hydrorrhoea  gravi- 
darum in  that  it  occurs  only  once.*  The  escape  of  the  decidual  secre- 
tion might  be  mistaken  for  that  of  the  amniotic  fluid,  which  may  be 
easily  distinguished  by  the  fact  that  the  latter  immediately  precedes 
delivery.  The  treatment  should  embrace  analeptic  and  tonic  measures, 
as  well  as  the  careful  avoidance  of  vaginal  douches  and  of  all  local 
irritation  tending  to  produce  abortion.  Should  uterine  contractions 
accompany  the  escape  of  the  decidual  fluid,  appropriate  anodyne  treat- 
ment must  be  adopted. 

Anomalies  of  the  Placenta. 

1.  Anomalies  of  Form.— The  usually  round  or  oval  placenta  may  be 
of  a  horseshoe  or  other  irregular  shape.  The  superficies  depends  upon 
the  extent  to  which  the  villi  form  vascular  connections  with  the  de- 
cidua. In  general  terms  it  may  be  stated  that  the  thickness  of  the 
placenta  is  in  inverse  proportion  to  its  surface  extension.     PlacentaB 

*  Spiegelberg.  Of.  cit..  p.  303. 


288  THE   PATHOLOGY  OF   PREGNANCY. 

succenturiatae,  small  accessory  placental  developments,  are  due  to  the 
persistence  of  isolated  villous  groups,  which  form  vascular  connections 
with  the  decidua  vera.  Placentas  spuria?  consist  of  circumscribed  de- 
velopments of  villi,  the  decidua  not  participating  in  the  growth.  A 
placenta  membranacea  is  a  broad  and  thin  vascular  membrane  pro- 
duced by  a  diffuse  proliferation  of  the  villi  over  the  entire  ovum,  form- 
ing vascular  connections  with  the  reflexa,  or,  where  the  latter  is  absent, 
with  the  vera. 

3.  Anomalies  of  Position. — The  placenta  may  be  attached  over  the 
OS  internum,  thus  constituting  placenta  praevia,  over  the  orifice  of  the 
Fallopian  tube,  or  in  connection  with  extra-uterine  pregnancy,  at  vari- 
ous points  in  the  abdominal  cavity. 

3.  Anomalies  of  Development.— A  hypertrophied  placenta  is  ab- 
normally large  in  proportion  to  the  size  of  the  foetus,  occurs  chiefly 
in  connection  with  hydramnion,  and  consists  of  a  genuine  parenchym- 
atous hyperplasia.  A  small  placenta  is  referable  either  to  defective 
development,  to  premature  involution,  or  to  hyperplasia  of  the  connect- 
ive tissue,  with  subsequent  contraction.* 

4.  Anomalies  of  Circulation. — Haemorrhage  into  the  placenta  is 
sometimes  produced  by  congestion  of  the  utero-placental  vessels,  due 
to  disturbances  in  the  motlier's  vascular  system,  f  The  extravasation 
may,  rarely,  be  intraplacental,  may  occur  into  the  serotina,  thus  con- 
stituting utero-placental  apoplexy,  or  may  take  place  into  the  uterine 
sinuses.  In  the  last  case,  thrombosis  of  the  placental  sinuses  is  said 
to  have  occurred. J  Placental  haematomata  are  the  above-mentioned 
collections  of  coagulated  blood  in  various  stages  of  disintegration.  The 
causes  of  the  haemorrhage  are  chiefly  morbid  changes  in  the  decidual 
vessels^  often  referable  to  placentitis.  The  extravasated  blood  usually 
experiences  the  ordinary  retrogressive  metamorphoses.  It  sometimes 
undergoes  cystic,  fatty,  or  calcareous  degeneration.  The  pressure  upon 
the  villi  produced  by  the  haematomata  impairs  the  nutrition  of  the 
foetus,  and  may  cause  the  death  of  the  latter. 

(Edema  of  the  placenta,  a  morbid  condition  usually  attributed  to 
derangement  of  the  fetal  or  umbilical  circulation,  is  characterized  by 
abnormal  pallor,  with  increased  size',  friability,  and  succulence  of  the 
placenta,  due  to  serous  infiltration.  The  morbid  anatomical  changes 
consist  essentially  in  cystic  dilatation  in  and  between  the  villi,  accom- 
panied sometimes  by  extravasations. 

5.  White  Infarctions  of  the  Placenta. — This  term  is  applied  to 
thickenings  of  the  placental  tissue,  varying  in  color  from  a  yellowish 
red  or  yellow  to  a  dirty  or  grayish  white.  They  have  a  dense  struct- 
ure, are  moderately  firm  in  young  infarctions,  with  more  of  a  fibrous 

*  Whitaker,  Am.  Jour,  of  Obstet,  August,  1870,  p.  229. 

t  Nouv.  Diet,  de  Med.  et  de  Chirurg.  Prat.,  vol.  xxviii,  Placenta,  p.  63. 

X  Slavjassky,  Arch.  f.  Gynaek..  v..  1878,.  p.  360. 


DISEASES  OF  THE  OVUM.  28<) 

character  in  older  ones.  In  size  they  vary  from  that  of  a  beau  to  that 
of  an  English  walnut.  For  the  most  part  they  are  sharply  circum- 
scribed ;  sometimes  flattened,  sometimes  oval  or  rounded  or  wedge- 
shaped.  In  some  cases  the  infarctions  send  out  radiate  processes. 
More  frequently  they  are  found  upon  the  maternal  surface  of  the  pla- 
centa. They  do,  however,  form  on  the  fetal  side.  They  may  extend 
through  from  surface  to  surface,  or  may  be  imbedded  in  the  placental 
substance. 

These  so-called  infarctions  apparently  are  due  primarily  to  a  hyaline 
degeneration  of  the  decidua.  The  same  process  extends  to  the  de- 
cidual vessels,  and  thence  to  the  intervillous  spaces.  In  these  a  coagu- 
lation of  the  blood  takes  place.  The  ensuing  compression  exerted 
upon  the  fetal  villi  leads  to  their  necrosis  and  obliteration.*  Fehling 
believes  that  rupture  of  the  maternal  vessels  due  to  endarteritis  may 
likewise  serve  as  the  primary  cause  of  the  compression  and  necrosis  of 
the  villi. 

White  infarctions  are  present  in  nearly  every  placenta.  AVhen  few 
in  number  and  of  small  size,  they  are  innocuous.  In  syphilis,  in  endo- 
metritis, in  nephritis  (Fehling),  etc.,  they  may  lead  to  extensive 
destruction  of  placental  tissue,  and  are  the  most  frequent  cause  of  the 
intra-uterine  death  of  the  foetus. 

6.  Degenerative  Changes. — (a)  Fatty  degeneration  of  the  placenta, 
circumscribed  or  diffused,  may  result  from  retrograde  changes  in  ex- 
travasations. When  developed  early  in  pregnancy,  it  is  sometimes  re- 
garded as  a  premature  completion  of  the  fatty  degeneration  normally 
occurring  at  the  end  of  pregnancy,  and  may  be  due  to  syphilis  or 
scrofula,  (b)  Amorphous  calcareous  deposits  are  frequent,  and  are 
almost  invariably  found  on  the  uterine  placental  surface,  in  the  decidua 
serotina.  Thence  the  process  may  extend  to  the  fetal  portion  of  the 
placenta.  When  the  calcareous  change  begins  in  the  fetal  tissues  it 
is  confined  to  these,  and  affects  the  small  blood-vessels  of  the  villi,  be- 
ginning in  their  terminal  ramifications  and  gradually  involving  their 
trunks,  (c)  Pigment  deposits,  resulting  usually  from  alterations  in  the 
hasmoglobin  of  extravasations,  are  found  in  both  healthy  and  diseased 
placentae  within  the  blood-sinuses  or  villi.  {(I)  Cysts  are  of  frequent 
occurrence  in  the  placenta.  They  are  found  near  the  center  of  its 
concave  surface,  and  vary  from  a  few  lines  to  several  inches  in  diameter. 
The  cyst-wall  is  covered  by  the  protruding  surface  of  the  amnion.  The 
fluid  in  the  cysts  contains  albumen  and  mucin.  Fenoinenow  f  regards 
these  cysts  as  the  product  of  the  placental  villi.  The  latter,  he  sup- 
poses, in  consequence  of  irritative  changes,  swell  and  undergo  a  partial 

*  For  resume  of  literature  of  the  subject  with  recent  observations,  vide  Jacob- 
sohn,  Untersuchungen  uber  die  Weissen  Infarcte  der  Placenta,  Ztschr.  fiir  Geb.  und 
Gynaek.,  vol.  xx,  p.  237. 

f  Fenomenow;  Zur  Pathologie  der  Placenta.  Arch.  f.  Gynaek.,  vol.  xv,  p.  343. 
19 


290  THE  PATHOLOGY  OF  PREGNANCY. 

loss  of  epithelium.  The  denuded  surfaces  adhere,  aud  thus  spaces  are 
formed.  The  fluid  he  regards  as  an  excessive  physiological  secretion 
from  that  portion  of  the  epithelium  which  remains  intact  upon  the 

villi. 

7.  Syphilis  of  the  Placenta.— In  placental  syphilis  the  placenta  is 
pale  and  heavy,  often  equaling  one  third  of  the  weight  of  the  fretus.  It 
only  exists,  according  to  Frankel,*  in  connection  with  congenital  or 
hereditary  fetal  syphilis.  It  involves  the  maternal  portion  of  the  pla- 
centa, when  the  mother  was  infected  either  before  or  soon  after  con- 
ception, and  produces  gummatous  proliferation  of  the  decidua,  charac- 
terized by  the  development  of  large-celled  connective  tissue,  with  occa- 
sional accumulations  of  younger  cells. 

When  the  infection  is  conveyed  by  the  father  to  the  foetus  alone, 
or  to  both  mother  and  foetus,  pathological  changes  occur  as  the  result 
of  a  chronic  inflammatory  process,  embracing  proliferation  of  the  cells 
and  connective  tissue  in  the  villi,  with  subsequent  obliteration  of  the 
vessels,  often  complicated  by  the  marked  proliferation  and  hardening 
of  their  epithelial  covering. 

The  affected  villi  become  swollen,  cloudy,  aud  thickened,  while 
their  epithelium  undergoes  proliferation  and  cloudy  swelling.  The 
parenchyma  of  the  villi  is  filled  Avith  lymph-cells,  and  the  vessels  are 
either  compressed  or  obliterated.  The  blood-sinuses  are  gradually 
encroached  upon  by  the  villi,  the  foetus  dies  from  lack  of  adequate 
nutrition,  and  the  villi  undergo  fatty  degeneration.  Portions  of  the 
healthy  placental  tissue,  which  often  intervene  between  the  diseased 
parts,  may  be  the  seat  of  extravasations. 

Anomalies  of  the  Amniox  and  of  the  Amniotic  Fluid. 

I.  Hydraxnnion. — Inasmuch  as  the  amount  of  the  liquor  amnii  va- 
ries considerably  within  normal  limits,  the  term  hydramnion  should 
be  restricted  to  those  cases  in  which  the  amount  of  fluid  is  so  large 
as  to  produce  morbid  symptoms  by  its  pressure  upon  the  uterus,  the 
abdominal  and  thoracic  viscera.  When  the  quantity  exceeds  tAvo  to 
three  pints,  inconveniences  are  often  experienced.  It  is,  hoAvever, 
usually  only  when  the  higher  degrees — viz.,  five  pints  and  upAvard — are 
reached  that  the  symptoms  possess  such  an  intensity  as  to  constitute  a 
special  malady. 

It  is  customary  to  distinguish  an  acute  and  a  chronic  form — in  the 
former  a  rapid  increase  in  the  size  of  the  abdomen  taking  place  in  a 
few  days,  or  even,  as  in  a  case  reported  by  Sentex,  in  a  single  night; 
whereas  in  the  latter  the  progress  is  slow,  extending  over  months,  and 
occasioning  infinitely  less  disturbance  of  function. 

Etiology. — The  causes  of  hydramnion  are  hardly  to  be  found  in  a 

*  FrXnkel,  Arch.  f.  Gynaek.,  v,  1873,  p.  52. 


DISEASP^S  OF  THE  OVUM.  291 

single  morbid  condition.  In  a  limited  number  of  cases— and  this  h 
especially  true  of  the  rare  acute  form,  though  even  in  these  not  in  all 
reported  instances— tlie  excessive  production  of  fluid  was  found  to  be 
associated  with  inflammation  of  the  amnion.  In  by  far  the  largest 
proportion  of  cases,  however,  the  evidence  is  strong  that  the  excess  of 
fluid  is  of  fetal  origin.  Sallinger's  *  experiments  show  that  when  a 
liquid  is  injected  into  the  umbilical  vein  it  transudes  witli  great 
rapidity  into  the  amniotic  sac,  and  that  the  amount  of  transudation  is 
proportioned  to  the  pressure  exerted,  and  to  the  size  of  the  cord. 
Jungbluth  described,  during  the  first  half  of  pregnancy,  a  capillary 
network  (vam  propria),  connected  with  the  vessels  of  the  umbilical 
cord,  developed  just  beneath  the  amnion,  in  that  portion  of  the  cho- 
rion which  covers  the  placenta.  Levison  f  found  that  this  capillary 
network  was  persistent  at  term  in  hydramnion,  but  not  in  nornud 
pregnancy.  Between  these  vessels  and  the  inner  surface  of  the  am- 
nion, canalicular  spaces  furnished  a  series  of  communicating  passages. 
Lebedjew  X  concluded  that  in  certain  abnormal  conditions  of  the  fa'tus 
found  associated  with  hydramnion  the  capillary  network  of  Jung- 
bluth was  persistent  to  the  end  of  pregnancy.  With  these  anatomical 
conditions  an  increased  secretion,  due  to  stasis  in  the  vasa  j^ropria, 
would  result  from  any  condition  causing  stenosis  of  the  umbilical  vein, 
from  obstructions  to  the  hepatic  circulation,  and  from  diseases  of  the 
fetal  heart  and  lungs.  In  this  connection  it  is  proper  to  observe  that 
syjDhilis,  and  especially  syi^hilitic  affections  of  the  liver,  are  frequently 
associated  with  hydramnion. 

Charpentier  found  that,  in  one  hundred  and  twenty-three  cases  of 
multiple  pregnancy,  fifty- two  were  cases  of  hydramnion.  Kiistner,* 
Schatz,||  and  Werth^  have  recently  drawn  attention  to  the  occurrence 
of  hydramnion  affecting  one  amniotic  sac  only  in  twins  developed  from 
the  same  ovum — i.  e.,  with  a  single  chorion,  the  sac  of  the  second  foetus 
containing  less  than  the  normal  quantity  of  fluid.  In  all  these  cases^ 
in  the  foetus  contained  in  the  hydramniotic  sac  both  heart  and  kid- 
neys were  hypertrophied,  and  the  amniotic  fluid  contained  an  unusual 
amount  of  urea.  The  cardiac  hypertrophy  Kiistner  ascribes  to  the 
appropriation  by  the  stronger  fcetus  of  the  placental  territory,  which 
in  twin  pregnancies  from  a  single  ovum  is  primarily  common  to  both 
foetuses.  The  increased  work  thus  entailed  upon  the  heart  leads  to  a 
thickening  of  its  Avails,  which  in  turn  is  followed  by  increased  growth 
and  activity  of   the  kidneys.     In  Kiistner's  cases  there  was  likewise 

*  Sallinger,  Dissert.  Inaugural,  Zurich,  1875. 

f  Levison,  Summary  in  Arch.  f.  Gynaek.,  vol.  ix,  p.  517. 

X  Lebed.jew,  vide  Traite  pratif^ue  des  accoucheraents,  par  Dr.  A.  Char[H'nticr, 
p.  886. 

*  KfsTNER.  Arch.  f.  Gynaek.,  vol.  xxi,  p.  1. 
II  ScHATZ,  Arch.  f.  Gynaek.,  vol.  xix.  p.  329. 
-^  Wertii,  Arch.  f.  Gynaek.,  vol.  xx,  p.  353. 


292  THE  PATHOLOGY  OP  PREGNANCY. 

hepatic  obstruction.  AVertli  suggests  that  the  activity  of  the  fetal  cir- 
culation  leads  to  more  active  absorption  on  the  part  of  the  placental 
villi,  and  that  the  insufficient  action  of  the  kidneys,  in  their  attempt 
to  maintain  the  necessary  equilibrium  in  the  fetal  circulation,  explains 
the  outpouring  of  fluid  not  only  into  the  amnion  but  into  the  serous 
cavities  of  the  fcetus,  as  is  often  observed  in  bydramnion. 

The  question  as  to  how  far  the  amniotic  fluid  may  be  of  maternal 
origin  is  still  an  undecided  one.  Ahlfeld  and  Leopold  maintain  that 
serum  may  pass  through  the  pores  in  the  chorion  and  amnion  from  the 
vessels  of  the  decidua  reflexa  (and  later  from  those  of  the  ova)  directly 
into  the  amnion.  Zuntz,  Wiener,  and  Bar  state  that  substances  experi- 
mentally injected  into  the  maternal  veins  may  be  found  in  the  amni- 
otic fluid  Avithout  having  first  traversed  the  body  of  the  foetus.* 

Symptoms  and  Signs.— The  distention  of  the  uterus,  and  the  conse- 
quent abnormal  expansion  of  the  abdomen  produced  by  hydramnion, 
results  in  an  impediment  to  locomotion,  and  causes  discomfort  or 
actual  pain  by  traction  upon  the  abdominal  parietes.  The  diaphragm 
is  forced  upward,  and,  encroacliing  upon  the  thoracic  space,  compresses 
the  lungs  and  displaces  the  heart,  thus  producing  dyspncea  and  car- 
diac palpitation.  The  urine  may  become  scanty  and  albuminous  from 
impeded  renal  circulation.  Neuralgic  pains  and  redema  of  the  abdomi- 
nal walls,  of  the  labia  and  lower  extremities,  are  produced  by  com- 
pression of  the  pelvic  nerves  and  vessels.  Vomiting  and  dyspeptic 
aymptoriis  result  from  direct  compression  of  the  digestive  organs  or 
from  reflex  irritation  of  them.  Ascites  may  be  produced  by  obstruc- 
tion of  the  portal  circulation.  Insomnia  results  from  the  patient's 
general  discomfort  and  the  deterioration  of  her  health.  In  the  acute 
form,  vomiting  is  often  incessant,  the  pain  is  intense,  and  febrile  symp- 
toms develop.  Physical  examination  reveals  in  advanced  cases  an  im- 
mensely distended  abdomen.  The  uterus,  which  can  be  easily  mapped 
out  by  palpation  and  percussion,  is  tense,  elastic,  and  obscurely 
fluctuating.  The  fetal  cardiac  sounds  are  faint  or  imperceptible. 
The  foetus  changes  its  position  with  unusual  rapidity  and  facility. 
Combined  manipulation  shows  the  lower  segment  of  the  uterus  to  be 
elastic  and  tense,  while  the  foetus  can  not  be  readily  felt  by  the  finger 
placed  in  contact  with  the  cervix.  Pregnancy  accompanied  by  hy- 
dramnion seldom  reaches  its  normal  termination,  delivery  being  pre- 
maturely induced  by  death  of  the  foetus,  by  separation  of  the  placenta, 
or  by  overdistention  of  the  uterus.  The  first  stage  of  labor  is  abnor- 
mally prolonged,  because  of  the  comparatively  feeble  contractions  of 
the  expanded  uterine  walls.  Labor  may  become  precipitate  in  the 
second  stage,  owing  to  the  sudden  escape  of  the  amniotic  fluid ;  and 
uterine  inertia,  in  the  third  stage,  frequently  results  in  post-partum 
liEemorrhage.  Involution  is  apt  to  be  protracted  and  incomplete. 
*  Vide  Charpentier,  Traite  pratique  des  accouchements,  p.  890. 


DISEASES  OF   THE  OVUM,  293 

Diagnosis.— Hydramnion  may  be  mistaken  for  twin  pregnancy, 
but  is  easily  excluded  by  the  rational  symptoms,  by  the  tenseness  of  the 
uterine  walls,  by  the  feebleness  or  absence  of  fetal  heart-sounds,  and 
by  the  difficulty  experienced  in  perceiving  the  foetus  on  palpation. 

Prognosis.— The  prognosis  for  the  child  is  fatal  in  nearly  one  fourth 
of  the  cases.  For  the  mother  it  is  favorable,  although  the  risk  of  po-sf- 
jmrtum  haemorrhage  is  considerable.  This  high  mortality  is  due  to 
malformations  of  the  foetus,  to  dropsical  affections,  to  prematurity, 
and  to  the  frequency  of  faulty  presentations.  Thus,  of  one  hundred 
and  thirteen  cases  collected  by  Charpentier,  twenty-one  presented  by 
the  breech,  twenty  by  the  shoulder,  and  two  by  the  face. 

Treatment. — The  treatment  embraces  the  application  of  an  abdomi- 
nal supporter  and  the  injunction  to  refrain  from  active  physical  ex- 
ertion. Grave  disturbances  of  the  mother's  heart  indicate  the  induc- 
tion of  premature  delivery,  which  should,  hoAvever,  in  the  interest  of 
the  child,  be  delayed  as  long  as  is  consistent  with  maternal  safety.  In 
parturition,  the  membranes  should  be  punctured  if  the  accumulated 
liquor  amnii  retards  the  dilatation  of  the  cervix.  Puncture  must  be 
performed  in  the  interval  of  the  jiains,  in  order  that  the  waters  may 
escape  gradually  and  leave  the  position  of  the  child  unchanged.  After 
the  expulsion  of  the  placenta,  the  usual  prophylactic  measures  against 
post-2)arf/nii  hemorrhage  must  be  promptly  adopted. 

II.  Abnormally  Small  Amount  of  Amniotic  Fluid. — The  quantity 
of  amniotic  fluid  may,  even  in  some  cases  of  advanced  pregnancy,  be 
so  limited  as  to  render  the  uterus  unusually  small  and  firm,  and  to 
limit  the  freedom  of  the  movements.  Under  these  circumstances, 
the  movements  are  so  plainly  perceptible  to  the  mother  as  to  be  the 
source  of  positive  discomfort. 

An  abnormally  small  quantity  of  liquor  amnii  is,  however,  only  of 
importance  in  the  earlier  stages  of  fetal  development.  If  the  amnion 
be  not  then  separated  from  the  fatus  by  an  adequate  amount  of  fluid, 
abnormal  amniotic  foldings  and  adhesions  between  the  amnion  and 
the  surface  of  the  foetus  may  take  place. 

The  so-called  foeto-amniotic  bands  *  thus  formed  may,  by  mechani- 
cal compression,  result  in  various  fetal  deformities,  or  in  spontaneous 
intra-uterine  amputation. 

AXOMALIES    OF   THE    UMBILICAL    CORD. 

I.  Torsion. — Torsion  consists  in  such  a  rotation  of  the  umbilical 
cord  upon  its  longitudinal  axis  that  its  vessels  are  thereby  rendered 
nearly  or  quite  impermeable.  It  occurs  most  frequently  in  foetuses 
which  have  advanced  beyond  the  middle  period  of  normal  utero-gesta- 
tion,  particularly,  according  to  Spiegelberg,t  in  those  of  the  seventh 

*  PuRST.  Arch.  f.  Gynaek.,  Bd.  ii,  171.  p.  :U8. 
■f  Spiegelberg,  LehrV)uch,  p.  'SHO. 


294: 


THE  PATHOLOGY  OF  PREGNANCY. 


mouth.  It  is,  however,  often  met  with  in  fcetuses  of  an  earlier  age. 
Until  a  comparatively  recent  period,  authors  have  unreservedly  attrib- 
uted torsion  to  active  movements  on  the  part  of  the  feftus,  and  re- 
garded it  as  the  cause  of  the  latter's  death.  Martin  *  has  shown  that 
this  theorv  is  untenable  for  the  majority  of  cases,  because  the  patho- 


FiG.  131.— Torsion  of  the  cord.    (Schauta."* 

logical  conditions  which  result  from  fetal  death  induced  by  torsion, 
whether  rapidly  or  slowly  produced,  are  almost  invariably  absent. 
These  morbid  anatomical  processes  embrace  rupture  of  the  umbilical 
blood-vessels,  and  extravasations,  for  cases  of  sudden  origin,  and  con- 
gestion, with  oedema,  for  those  more  gradually  developed.     Martin 

*  Martin,  Ztschr.  f.  Gebnrtsh.  ii.  Gynaek..  Rd.  ii.  Heft  2,  1878,  p.  346. 


DISEASES  OF  THE  OVUM.  295 

therefore  concluded  that  torsion  was  o.  post-mortem  event,  resulting 
from  rotation  of  the  foetus  produced  by  maternal  movements.  Ruo-e* 
earnestly  advocated  the  same  view,  and  suggested  the  various  morbid 
changes  due  to  syphilis,  endometritis  placentaris,  and  sub-placental 
hemorrhage  as  the  cause  of  fetal  death  in  cases  which  subsequently 
developed  numerous  torsions.  Schauta  \  appears  as  a  recent  champion 
of  the  same  theory,  although  he  admits  that  loose  torsions,  incapable 
of  producing  actual  stenosis  of  the  umbilical  vessels,  may  often  occur 
during  the  life  of  the  fcetus.  He  bases  his  belief  in  the  post-mortem 
occurrence  of  torsion — 1.  Upon  the  large  number  of  twists  often  pre- 
senting themselves,  any  one  of  which  would  have  involved  the  death 
of  the  foetus.  Even  granting  the  original  torsion  to  have  been  of  ante- 
mortem  origin,  the  others  must  then  have  occurred  after  death.  2. 
Upon  the  improbability  of  the  formation  of  very  numerous  torsions  in 
a  healthy  cord,  inasmuch  as  its  elasticity  would  lead  to  comj^ensatory 
reverse  rotation.  3.  Upon  the  fact  that  even  twenty-five  artificially 
induced  torsions  resulted  in  rupture  of  the  normal  cord  from  excessive 
tension.  Schauta  regards  the  cysts  found  in  connection  with  some 
torsions  as  insufficient  proof  of  their  ante-mortem  occurrence.  Tor- 
sions are  more  frequently  present  in  the  umbilical  cords  of  male  than 
in  those  of  female  foetuses,  and  are  sometimes  surprisingly  numerous. 
Schauta  reports  a  case  in  which  he  observed  three  hundred  aud  eighty 
rotations  of  the  cord  on  its  longitudinal  axis.  It  occurs  by  preference 
in  multiparae,  probably  on  account  of  the  greater  latitude  afforded  for 
fetal  movements.  Unusual  length  of  the  cord  favors  its  occurrence, 
for  a  similar  reason.  The  seat  of  the  torsion  is  ordinarily  in  close 
proximity  to  the  umbilicus.  It  occurs  but  rarely  at  the  placental  end 
or  in  the  center  of  the  cord.  The  umbilical  vessels  are  usually  nearly 
occluded  at  -the  seat  of  the  torsion,  but 
still  permeable.  Thrombi  of  varying 
consistency  are  often  found  in  the  ves- 
sels. Sero-sanguinolent  fluid  in  the  ab- 
dominal cavity  of  the  foetus,  oedema,  and 
cystic  degeneration  of  the  cord,  are  also 
pathological  conditions  frequently  at- 
tending torsion. 

II.  Knots. — Knots  in  the   umbilical 
cord,  which  occur  once  in  two  hundred  ^      , .,.    , 

Fig.  132.— Knot  of  umbilical  conl. 

cases,  may  result  from  the  passage  oi  the  iLeyman.i 

foetus  through  a  twisted  loop  of  the  cord, 

whether  the  passage  be  effected  during  pregnancy  by  the  spontaneous 

fetal  movements,  or  at  term  by  the  uterine  expulsive  efforts,  or  by  the 

manipulations  of  the  accoucheur.     Knots  formed  during  parturition 

*  RuGE,  ihid.,  Bd.  iii,  Heft  2, 1878,  p.  417. 

f  Schauta,  Arch.  f.  Gynaek.,  Bd.  xvii,  Heftl,  1881.  p.  20. 


296  THE  PATHOLOGY  OF  PREGNANCY. 

are  loose  and  easily  untied.  They  are  unattended  by  any  diminution 
in  the  gelatin  of  Wharton.  Those  occurring  during  pregnancy  are 
more  closely  and  firmly  drawn,  and  more  difficult  to  loosen  than  the 
former  variety.  The  cord  is  partly  or  completely  denuded  of  the 
gelatin  at  the  seat  of  the  knot,  and  plainly  shows  the  location  of 
the  latter,  after  its  solution,  by  well-marked  indentations.  Knots  in 
the  cord,  of  either  variety,  are  comparatively  insignificant,  although  a 
tightly  contracted  one,  in  a  thin  cord,  may  occasion  grave  or  even 
fatal  disturbance  of  the  ujnbilical  circulation. 

III.  Hernia. — Hernia  of  the  umbilical  cord  consists  in  the  escape 
from  the  abdomen,  at  the  point  of  insertion  of  the  cord,  of  some  or  all 
of  the  fetal  abdominal  viscera.  It  is  due  either  to  arrested  embryonic 
development,  which  prevents  the  complete  closure  of  the  abdominal 
cavity,  or  to  the  failure  of  the  fetal  intestines,  originally  situated  out- 
side the  abdomen,  to  enter  the  same.  Hernia  of  the  cord  may  occur 
alone,  in  otherwise  normally  developed  foetuses,  but  is  usually  accom- 
panied by  other  deformities,  such  as  stricture  of  the  rectum,  imper- 
forate anus,  or  distortions  of  the  lower  limbs  and  of  the  genitals,  pro- 
duced by  traction  of  the  displaced  viscera  upon  adjoining  parts.  The 
contents  of  the  hernial  sac,  which  is  composed  of  the  amnion  and  of 
the  peritouiBum,  are  usually  convolutions  of  the  intestine,  or  these 
with  a  portion  of  the  liver,  although  the  kidneys,  stomach,  and  sjDleen 
are  sometimes  also  extruded,  leaving  the  fetal  abdomen  nearly  empty. 

IV.  Coiling  of  the  Cord. — Windings  of  the  umbilical  cord  around 
the  foetus,  occurring  during  pregnancy,  vary  in  their  results  with  the 
rapidity  of  their  formation.  When  rapidly  developed,  they  may  in 
rare  cases  lead  to  sudden  interruption  of  the  umbilical  circulation, 
and  to  consequent  death  of  the  foetus.  Should  the  coils  be  gradually 
formed  and  firm,  the  extremity  embraced  by  the  cord  increases,  by  its 
own  growth,  the  tightness  of  the  constricting  ligature.  The  latter 
slowly  lessens  the  caliber  of  the  vessels  supplying  the  extremity  con- 
cerned, and  finally,  occluding  them,  produces  death  of  the  limb.  Ab- 
sorption of  the  soft  and  hard  parts  of  the  extremity  may  result  from 
the  cord's  unyielding  pressure,  and  the  limb  be  thus  completely 
severed  from  the  trunk  by  so-called  spontaneous  amputation.  In  cer- 
tain cases  the  combined  pressure  of  the  cord  and  of  the  slowly  grow- 
ing member  may  suffice  to  completely  arrest  the  umbilical  circulation, 
and  thus  produce  the  death  of  the  foetus.  Should  the  neck  be  encir- 
cled by  the  cord,  death  may  ensue  from  strangulation,  and  be  followed 
in  some  cases  by  almost  complete  amputation  of  the  head.  Coilings 
of  the  cord  around  the  foetus  occurring  at  birth  are  of  little  impor- 
tance unless  they  be  numerous.  In  that  case  they  lead  to  a  shorten- 
ing of  the  cord,  and  produce  anomalous  positions,  premature  separa- 
tion of  the  placenta,  retarded  second  stage  of  labor,  and  even  death  of 
the  foetus  from  interference  of  the  umbilical  circulation. 


DISEASES  OF  THE  OVUxM. 


297 


V.  Cysts.— Cysts  of  the  umbilical  cord  within  the  amniotic  sheath 
are  either  produced  by  liquefaction  of  mucoid  tissue,  or  by  accumula- 
tion of  serum  between  the  epithelial  layers  of  the  allantois. 

VI.  Stenosis  of  Umbilical  Vessels.— Partial  occlusion  of  the  um- 
bilical vein  at  the  placental  insertion,  produced  by  new  connective 
tissue  resulting  from  circumscribed  periphlebitis,  is  sometimes  ob- 
served, but  is  not  sufficiently  marked  to  impede  the  umbilical  circula- 
tion. Stenosis  of  the  umbilical  arteries  is  occasionally  produced  by 
atheroma  and  subsequent  thrombosis.     Stenosis  of  the  umbilical  vein, 


Fig.  133.— Insertio  velamentosa.    (Lobstein.) 


and,  more  rarely,  of  the  arteries,  may  also  result  from  chronic  phlebitis 
characterized  pathologically  by  the  growth  in  the  intima  of  spindle- 
shaped  and  round   cells,  which  later  develop  into   new  connective 


298  THE  PATHOLOGY  OP  PREGNANCY. 

tissue.  This  process,  whicli  is  usually  referred  to  hereditary  syphilis  * 
may  extend  into  the  muscularis,  and  even  invade  the  adventitia.  The 
result  of  the  stenosis  of  the  uterine  vessels  is,  of  course,  prejudicial  to 
the  foetus  in  direct  proportion  to  its  grade  of  development. 

VII.  Calcareous  Degeneration.— Calcareous  deposits  have  been  ob- 
served in  the  cords  of  syphilitic  foetuses. 

VIII.  Marginal  Insertion  of  the  Cord.— This  anomaly  is  sometimes 
called  the  battledoor  placenta,  while  the  term  iiisertio  velamentosa  is 
applied  to  cases  where  the  vessels  of  the  cord  pursue  their  course  for 
some  distance  through  the  membranes  before  reaching  the  placenta. 
To  comprehend  their  origin,  it  is  necessary  to  recall  the  main  physio- 
logical processes  involved  in  the  normal  development  of  the  placental 
organ.  The  vessels  of  the  allantois  are  not  invariably  carried  at  the 
outset  to  the  point  in  the  periphery  of  the  ovum  which  the  placenta 
will  ultimately  occupy.  The  vessels  at  first  penetrate  all  the  villi  in- 
discriminately, but  as  the  process  of  obliteration  advances  in  those 
villi  not  destined  to  participate  in  the  formation  of  the  placenta,  vas- 
cular connections  are  only  preserved  between  the  vessels  of  the  newly 
formed  cord  and  the  villi  attached  to  the  serotina.  As  the  amniotic 
sheath  forms  around  the  rudimentary  cord,  the  foetus  performs  a 
movement  of  rotation  in  such  a  way  that  the  umbilical  vessels  are 
made  to  pursue  a  direct  course  toward  their  placental  insertion.  If, 
owing  to  the  adhesions  between  the  rudimentary  cord  and  either  the 
chorion  or  the  amnion,  the  formation  of  the  sheath  is  incomplete,  the 
vessels  diverge,  and  are  distributed  to  points  more  or  less  distant  from 
the  placenta  (Schultze).  In  the  insertio  velamentosa  (Fig.  133), 
hgemorrhage  sometimes  results  from  a  rupture  of  a  vessel  at  the  time 
of  the  breaking  of  the  membranes — an  accident  which,  unless  speedily 
followed  by  delivery,  is  apt  to  prove  fatal  to  the  foetus. 

IIydatidiform  Mole. 

I.  Morbid  Anatomy. — Before  the  time  of  Cruveilhier,  who  is  said 
to  have  first  demonstrated  the  difference  between  true  hydatids  and 
the  uterine  hyd;  tidiform  mole,  these  morbid  formations  were  regarded 
as  identical.  Since  his  researches,  it  has  been  considered  established 
that  the  essential  pathological  process  involved  in  the  production  of 
the  hydatid  mole  consists  in  a  proliferative  degeneration  of  the  chori- 
onic villi.  This  degeneration  of  the  villi  embraces  h^'pertrophy  of 
their  investing  epithelium,  of  their  connective-tissue  cells,  which  may 
also  undergo  mucoid  degeneration,  and  of  their  mucoid  intercellular 
substance.  The  accumulation  of  the  mucoid  tissue  imparts  to  the  villi 
the  appearance  of  cysts  with  translucent,  semi-fluid  contents,  varying 
in  size  from  that  of  a  millet-seed  to  that  of  a  walnut,  and  forming,  by 

*  Mewis.  Ztschr.  f.  Geburtsh.  u.  Gynaek.,  Bd.  iv,  Heft  1,  1879,  p.  62. 


DISEASES   OF   THE   OVUM. 


290 


their  aggregation,  growths  which  may  attain  the  dimensions  of  a  child's 
Jiead,  or  in  rare  cases  may  reach  such  proportions  as  to  distend  the 
uterus  to  the  size  usual  at  the  full  term  of  pregnancv.  Smaller  collec- 
tions are  much  more  frequently  encountered  than  those  of  these 
enormous  proportions.  The  fluid  of  the  cysts  is  albuminous,  and  closely 
resembles  the  liquor  amnii,  but  contains  in  the  earlier  stages  a  larger 
proportion  of  mucin  than  the  latter.  At  a  later  period  the  mucin  is 
less  abundant,  while  the  albumen  increases  in  quantity.  The  larger 
cysts  are  richer  in  water,  but  contain  less  mucin  than  the  smaller  ones. 
Inasmuch  as  the  degenerative  process  does  not  attack  the  entire  villus, 
portions  of  normal  tissue  intervene 
between  the  cysts,  and  impart  to 
tlie  degenerated  mass  the  appear- 
ance of  grape-clusters — the  cysts 
i-epresenting  the  individual  berries, 
and  the  unaltered  tissues  their  con- 
necting stems.  A  certain  number 
of  cysts  are,  however,  attached  to 
a  single  continuous  pedicle,  instead 
of  possessing  a  separate  stem  con- 
nected with  a  common  trunk,  as  is 
the  case  in  the  grape-cluster.  If 
the  mole  be  formed,  as  is  usually 
the  case,  during  the  first  month, 
while  the  villi  are  equally  devel- 
oped upon  the  entire  perij^hery  of 
the  ovum,  the  degeneration  will 
involve  its  whole  surface.  In  this 
case  the  foetus,  dying  and  becoming 
disintegrated,  may  undergo  com- 
plete absorption,  leaving  the  amni- 
otic cavity  emf>ty.     The  vessels  of 

the  villi  are  under  such  circumstances  completely  obliterated,  while  nu- 
Tuerous  blood -coagula  are  found  between  the  cysts.  If,  however,  the 
placenta  be  already  formed  at  the  beginning  of  the  cystic  degeneration, 
the  villi  having  become  atrophied  upon  that  part  of  the  chorion  which 
does  not  participate  in  the  development  of  the  placenta,  the  neoplasni 
is  confined,  as  a  rule,  to  the  latter,  although  cysts,  evidently  owing  their 
origin  to  villi  which  have  not  undergone  atrophy,  sometimes  occur 
upon  the  smooth  surface  of  the  chorion.  Should  the  hydatidiform 
mole  be  of  sufficient  extent,  under  these  circumstances,  to  destroy  the 
foetus,  the  more  or  less  disintegrated  remains  of  the  latter  are  found 
in  the  am.niotic  cavity,  which  sometimes  contains  an  excess  of  liquor 
amnii.  If  only  a  few  of  the  placental  lobes  or  single  cotyledons  be 
implicated,  the  growth  of  tlie  foetus  may  not  be  disturbed.     A  healthy 


Fig    1« 


-SpenMieii  tiom  liMlatuliform  mole, 
m  the  Wood  JIuseum 


300  THE  PATHOLOGY  OF  PREGNANCY. 

fostus  is  occasionally  developed  side  by  side  with  a  hydatid  mole.* 
The  hydatidiform  mole  is  usually  contained  within  the  decidua.  In 
an  interesting  case  reported  by  Volkmann,  however,f  the  degenerated 
villi  had  invaded  the  uterine  blood-sinuses,  and  by  pressure  led  to  so 
extensive  an  atrophy  and  absorption  of  the  uterine  walls  as  to  leave 
only  a  thin,  transparent  septum  between  the  mole  and  the  peritoneal 
covering  of  the  organ.  The  cavity  formed  by  this  process  of  erosion 
in  the  uterine  parenchyma  was  larger  than  the  uterine  cavity  proper, 
and  presented  numerous  intersecting  trabecule  resembling  the  columnar 
carneae  of  the  cardiac  ventricles.  The  destructive  character  of  the 
cystic  degeneration  is  attributed  in  such  cases  to  some  unknown  mor- 
bid condition  of  the  uterine  walls,  probably  the  result  of  malnutrition. 
Schroeder  J  refers  to  two  similar  cases,  in  one  of  which  the  cystic  de- 
generation was  attended  by  fatal  peritonitis,  and  the  other  by  rupture 
of  the  uterus,  and  death  from  hfemorrhage  into  the  peritoneal  cavity. 

II.  Etiology. — Primiparffi  are  less  frequently  affected  by  the  hyda- 
tidiform mole  than  multiparae,  although  the  actual  number  of  preg- 
nancies seems  to  exert  a  less  marked  predisposing  influence  than  ad- 
vancing age.  The  cystic  degeneration  usually  occurs  during  the  first 
month  of  utero-gestation.  According  to  Underbill,**  the  latter  part 
of  the  third  month  is  the  limit  within  which  the  disease  can  originate. 
That  the  exciting  cause  of  the  hydatidiform  mole  may  be  a  morbid  ma- 
ternal condition,  is  rendered  probable  by  the  repeated  recurrence  of  the 
disease  in  the  same  patient,  by  its  coexistence  with  inflammatory  de- 
cidual disease  or  with  extensive  uterine  fibroids,  and  by  the  presence, 
in  the  majority  of  cases,  of  a  cancerous  or  syphilitic  dyscrasia  on  the 
part  of  the  mother.  If  the  origin  of  the  degeneration  be  maternal,  as 
it  probably  is  in  most  instances,  the  degeneration  of  the  chorion  ante- 
dates and  produces  the  death  of  the  foetus.  On  the  other  hand,  the 
fact  that  the  morbid  growth  may  owe  its  inception  to  fetal  disease 
seems  demonstrated  by  those  cases  in  which,  as  has  been  already  stated, 
a  healthy  foetus  may  be  developed  at  the  same  moment  with  a  hydatidi- 
form mole.  This  view  is  further  supported  by  those  cases  in  whidi 
death  of  the  foetus  is  attended  by  so  insignificant  an  amount  of  cho- 
rionic disease  as  to  render  its  active  causative  agency  in  the  death  of 
the  foetus  highly  improbable.  Spiegelberg,||  however,  is  of  the  opinion 
that  the  hydatidiform  mole  does  not  result  from  death  of  the  embryo, 
and  that  its  cause  is  often  to  be  sought  in  an  abnormal  development  of 
the  allantois.  The  establishment  of  the  true  pathological  relations  of 
the  hydatidiform  mole  have  led  to  the  abandonment  of  the  once  preva- 

*  Spiegelberg,  Lehrbiich,  p.  332. 

f  Volkmann,  Virchow's  Archiv,  Bel.  xli.  p.  528. 

I  ScHROEDER,  Lehrbuch,  p.  429. 

*  Underhill,  The  Hydatidiform  Mole,  Obstet.  Gaz.,  January,  1879,  p.  16. 

II  Spiegelberg,  Lehrbuch,  p.  333. 


DISEASES  OF  THE   OVUM. 


301 


lent  opinion  that  the  neoplasm  might  be  developed  independent  of 
conception.  The  theory  that  a  portion  of  retained  placenta  might 
become  affected  with  the  hydatidiform  disease,  has  also  been  refuted 
by  accumulated  clinical  evidence. 

III.  Symptomatology. — A  leading  sign  of  the  hydatidiform  mole 
consists  ill  a  failure  of  correspondence  between  the  uterine  enlarge- 
ment and  the  computed  period  of  utero-gestation.  The  uterus  is 
usually  larger  at  any  given  stage  of  pregnancy  than  it  naturally  would 
be  in  the  course  of  normal  gestation,  but  may  be  decidedly  smaller  in 
those  cases  attended  by  early  demise  of  the  embryo.  Lumbar  and 
sacral  pains  are  prominent  and  distressing  in  proportion  to  the  rapid- 
ity of  uterine  development.  The  uterus  imparts  a  peculiar  doughy 
feeling  to  the  palpating  fingers,  and  in  rare  instances  plainly  jjercep- 
tible  fluctuation.  Individual  parts  of  the  foetus  can  not  be  distin- 
guished through  the  uterine  walls.  The  lower  segment  of  the  uterus 
is  remarkably  tense.  Ballottement  yields  negative  results  and  fetal 
movements  are  absent,  although  they  may  be  closely  simulated  by  uter- 
ine contractions.  The  fetal  cardiac  sounds  are  diminished  in  inten- 
sity or  are  quite  imperceptible.  There  is  a  discharge  from  the  uterus, 
either  constant  or  intermittent,  consisting  of  disintegrated  and  unrupt- 
ured cysts,  cystic  fluid,  and  blood,  which,  although  usually  not  excess- 
ive^  may  be  so  much  increased  by  uterine  contractions  induced  by 
overdistention  as  to  seriously  impair  the  general  strength,  or  even  to 
induce  death  from  exhaustion. 

Abortion  is  usually  produced  by  the  mole  before  the  sixth  month, 
but  the  expulsion  of  the  neoplasm  may  be  delayed  until  the  normal 
period  of  parturition,  or  even  until  a  later  season.  The  haemorrhage 
and  the  characteristic  discharge  cease  after  the  complete  expulsion  of 
the  tumor,  but  retained  portions  of  the  same  may  give  rise  to  pro- 
tracted bleeding.  It  is  often  impossible  to  distinguish  the  local  signs 
produced  by  the  expulsion  of  a  large  hydatidiform  mass  from  those 
observed  after  normal  delivery. 

Diagnosis. — In  cases  of  limited  cystic  degeneration  it  is  often  im- 
possible to  diagnosticate  hydatidiform  mole.  The  symptoms  upon 
which,  in  well-marked  cases,  the  diagnosis  is  to  be  based  are  rapid  in- 
crease in  the  dimensions  of  the  uterus,  the  presence  of  obscure  fluctu- 
ation, the  impossibility  of  obtaining  the  fetal  heart-sounds  or  of  grasp- 
ing any  of  the  fetal  members,  negative  result  of  ballottement,  and 
uterine  contractions,  attended  by  the  mucous  or  muco-sanguiuolent 
discharge  containing  the  characteristic  cysts. 

Prognosis.— The  prognosis  of  hydatidiform  mole  is  determined 
chiefly  by  the  frequency  and  the  violence  of  the  attending  haemor- 
rhages. It  is  not  extremely  unfavorable  in  the  majority  of  cases. 
The  existence  of  the  peculiar  form  of  cystic  degeneration  described 
as  the  interstitial,  intraparietal,  or  eroding  variety  would,  however, 


302  THE  PATHOLOGY  OF  PREGNANCY. 

iiuturally  render  the  prognosis  excee;lingly  gruve.  'V\\v  fatality  of 
tliis  class  of  cases  results  from  their  tendency  to  produce  a  rni)ture  of 
the  uterus  complicated  by  intra])eritoneal  ha'morrhage,  peritonitis,  or 
septicaemia.     The  life  of  the  fcetus  is  almost  invariably  sacrificed. 

Treatment.— The  treatment  is  restricted  to  measures  calculated  to 
control  ha'morrhage  and  to  promote  the  ex])ulsion  of  the  diseased 
mass.  Most  writers  recommend  non-interference  so  long  as  the  ute- 
rus remains  passive.  When  contractions  set  in,  the  vagina  should  be 
tamponed,  and  ergot  given  in  full  and  repeated  doses,  until  the  mole 
is  expelled  entire.  The  expectant  plan  is,  however,  not  devoid  of 
danger.  In  once  case,  where  the  patient  sulfered  from  labor-pains 
for  several  hours  before  I  saw  her,  the  loss  of  blood  was  excessive.  I 
succeeded  in  removing  with  the  hand,  through  the  patulous  cervix, 
an  enormous  quantity  of  cysts,  suthcient  to  lill  a  wooden  ])ail.  This 
was  followed  by  good  contraction  of  the  uterus  anil  arrest  of  the 
hemorrhage,  but  the  patient  died  two  hours  later  from  shock  and 
anremia.  Unless,  therefore,  the  patient  is  so  placed  that  professional 
assistance  can  be  obtained  at  a  moment's  notice,  the  propriety  of  dilat- 
ing the  cervix  so  soon  as  the  diagnosis  has  been  established  may  well 
be  considered.  Dilatation  should  be  effected  by  the  steel  dilator,  or  by 
the  dilators  of  Barnes  or  of  Tarnier,  or  even  by  tents,  if  rare  is  taken 
to  render  them  thoroughly  aseptic. 

After  expulsion,  or  after  the  manual  removal  of  the  hydatidiform 
(iysts,  the  uterus  should  be  washed  out  with  antiseptic  fluids;  or,  in 
case  of  hiemorrhage,  its  inner  surface  should  be  swabbed  with  the  per- 
chloride  of  iron.  The  irrigation  of  the  uterine  cavity  with  water,  to 
which  only  sufficient  perchloride  of  iron  has  been  added  to  give  it  a 
wine-color,  has  often  a  powerful  styptic  effect.  Underbill  recom- 
mends the  continued  einployment  of  ergot  after  delivery,  and,  in 
cases  of  persistent  ha;morrhage,  the  occasional  introduction  of  the 
laminaria  tent,  and,  if  necessary,  the  employment  of  Thomas's  dull- 
wire  curette. 

Retention  in  Utero  of  the  Dead  Fcetus. 

In  the  normal  uterus  the  causative  conditions  producing  retention 
of  the  dead  fcetus  are  not  invariably  identical.  If  the  placenta  remain 
adherent  to  the  uterus  after  the  demise  ojf  the  foetus,  the  continued 
vitality  and  uninterrupted  development  of  the  placenta  sufficiently 
explain  the  fetal  retention.  When,  however,  all  connection  between 
the  placenta  and  the  uterus  has  been  severed,  retention  is  probably 
i-eferable  to  the  diminished  irritability  of  those  reflex  nervous  centers 
which  control  the  expulsive  uterine  efforts.  The  duration  of  retention 
produced  by  adhesion  of  the  placenta,  in  cases  of  single  pregnancy,  is 
protracted  until  such  time  as  morbid  placental  processes  impair  the 
vitality  of  that  organ  and  induce  its  separation.     In  multiple  preg- 


niSKASlW   OK    'I'll!-;   OVUM.  ;{,);{ 

nanoios,  aUciult'd  by  tli'Mlli  of  <»iic  or  nunc  of  l.li»>  fd'liiKcs,  Liu?  laUt-r 
arcMisiially  oxpolli^d  willi  llio  lioiilUiy  I'cnlus  al.  tonii.  Tlicy  aro,  liow- 
ovcir,  tt()iiiol,irti(>K  cxprllcd  carlior,  and,  in  iiin<  inHlaih-cH,  lalcr  llian  lll(^ 
iiornnil  fdttus,  and  it  nii.y  in  ^cncM-al  (criiiH  Ix!  staled  thai,  rctcniion 
pnxInriMl  hy  placcidal  adlicsion  vnry  rarely  (ixccccIh  llin  natural  period 
of  ^fKHtaXioii.  Ifelcniion  due  to  diniinislied  irritaliilily  <d'  llie  rellex 
CdiitcrH  may  iKMndelinildy  prolon^cil.  Licihiininu  *  Ih  of  t.lie  npinion 
tliat,  all  (laseH  of  rcdciit.ion  protracted  l»ey(in<l  tJie  norniid  term  (»!'  pre;;- 
lUiiK^y  heloM^'  in  (JiiH  calc^^ory. 

'riio  pailiolo^i(!al  (dnui^^cH  which  the  l'(etiis  underyoes  when  retained 
in  the  ntcruH  af(.(!r  il,H  death  vary  with  the  e(»nditi<»n  <d' I  he.  nieinhranew; 
!.  if  their  iid.e/^ril,y  bo  |»r('.H(!rv()(l,  (In*  tiioHl,  iniporliiid.  pat holojL,deal  fetal 
eondit.ioiiH  reHidl.in;^'  from  the  retention  urv  mnmmilieation,  maeera- 
iion,  uiid  fatly  de;^renei-aJion.  "I.  l(  the  niendirnneM  be  rnptnred  noun 
aftor  the  doath  of  the  fcetns,  or  if  their  rnptiin'  be  the  eaiise  of  I  be 
Icr'minatioti  of  fetal  life,  mum miliea^tion  ma,y  (>nKii(t;  or,  in  tlnwYent. 
of  th(!  entraiKio  of  air  itd.o  the  uterine!  cavity,  I  he  fetal  IJHHueH  may 
undergo  fjutrofacstivo  chaiigttH.  If  nMininiilieidion  h;is  idre;idy  iicenrred, 
pulref.iclion  docH  not,  tako  phice.f 

Muilllliilioaliun.  Mummilii-nJion  h  niont  fr<'(piently  oliHerved  in  fo'- 
tuHOH  whoH(!  (loath  haH  apparoiilly  b(H'n  the  gradual  residt  of  inanition 
from  imido(|uato  hlood-Kup|)ly,  this  inHid!i<'iency  of  the  nuttilive  fluid 
Ixiitig  oftoM  roforablo  to  torHion  or  c(»nHtri<!tion  of  the  undiili(:d  eoid. 
Miimmi(i(ralion  alVeets  by  pr<d'i'rence  fo'tuKOH  dying  during  the  midtlle 
HtagoH  of  g('st,a,tion.  liiebmann  J  HuggentH  thn,t  tJus  fact  nniy  be  eon- 
nocitod  with  the  itugmenled  r;ipi(|it,y  of  endonmosiH,  du(!  to  tho  larger 
{»or(!()id,age  of  Halinc!  ingr<'(lient.s  then  prcHoid-  in  tho  jininiotic  (luid, 
or  to  tli(!  fact  that  torsion  and  Hl,(fMOHiH  «)f  tluj  (!ord  are  rnoHt  liable  to 
oecui-  id  Ib.d,  period  (d'  pregnaiKiy.  M  umnnlication  oceurn  chielly  in 
(!onnoetioti  with  twin  pregnnricioM,  one  f(etun  Infiiig  fully  d(!veloped 
whiici  th(f  otluir  bocom<!H  mummilied.  iu  tJuH  cuho  tho  pnworKicf  of  the 
(l(!!id  fo'tuH  «loeH  not  usually  (^xcito  ttxpulsory  uterine  (dVorls  lad'orc!  Ilie 
nornuil  tornumition  of  prognatiey  is  reached,  when  both  fietuHos  are 
HimultanooiiHly  (hflivcfrod.  in  <:<'rl!iin  r.ire  instances  the  inumrrMlied 
fo'tiis  nuiy  Ix'  ex|»ell(!d  either  before  or  after  the  healthy  on<',  but  its 
delivery  is  uiiMttcnded  by  liM'tnorrhagc)  or  other  unphfusant  complica- 
tion. When  niiiinniilicMti<.n  ;dTe(!ts  a  singlo  foftuH,  the  retention  is 
supposeil  t(»  be  due  to  abiiornuilly  irdimate  eoruMtction  between  Iho 
placenta  and  tlu!  ut,oniH.  Symptoms  closctly  sirnidatitig  thoHo  of  abor- 
tion oc(!ur,  l>ut  tluty  subside  Ix-fore  the  pnxluct  «»f  (ionception  is  ex- 
pollod,  and  probal)ly  (!veu  befon-  the  ruptun*  of  tho  mend)ranes.  Tho 
UiituH  thori   bocotrios   mumnnlied,  wlnle  the   vitality  <»f   the  pla.cnta  is 

*^  Ln';iiMANN,  fkit,niK/.  (loharlMli.  ii.  (iynwU.,  IM.  hi.  IH?I,  \>\>.W,  (V.i. 
f  SiMKiH'-i-UKiuj,  liiilirh,,  p.  'M7. 
J  LrKHMANN,  op.  cil.,  p.  M. 


304  THE  PATHOLOGY  OF  PREGNANCY. 

not  impaired.  Under  these  circumstances  the  retention  is  never  jiro- 
longed  beyond  the  normal  period  of  gestation,  and  is  thus  distin- 
guished from  those  cases  of  retention  owing  their  origin  to  so-called 
"  missed  labor." 

A  mummified  ftetus  is  flattened  from  compression.  Its  viscera  are 
of  soft  consistency  and  of  small  dimensions.  Its  surface  is  shrunken. 
The  peritoneal  and  pleural  cavities  contain  a  scanty  and  discolored 
fluid.  The  subcutaneous  areolar  tissue  has  disappeared,  and  the  skin 
lies  in  direct  contact  with  the  muscles.  The  placenta,  Avhich  is  dry, 
yellowish,  and  tough,  is  the  seat  of  fatty  degeneration,  and  contains 
the  residue  of  old  extravasations. 

Maceration. — The  placenta  of  a  macerated  fretus  (fcetus  sanguino- 
lentus)  is  ana3mic,  soft,  and  friable.  The  cord,  in  wliich  the  vessels 
are  permeable,  is  cylindrical,  smooth,  spongy,  and  inelastic.  Its  coils 
have  disappeared.  It  is  club-shajied  at  the  fetal  extremity,  and  its 
color  is  brownish  red.  The  amniotic  fluid  has  a  peculiarly  repulsive, 
sweetish,  and  sickening  odor,  unlike  that  of  putrefaction.  The  fluid 
is  rendered  turbid  and  of  a  greenish-yellow  color  by  the  admixture  with 
it  of  sero-sanguinolent  fluid,  and  of  meconium.  The  membranes, 
which  retain  their  normal  consistence  for  a  long  time,  finally  become 
friable,  swollen,  and  discolored.  A  foetus  of  only  one  to  two  months 
may  be  completely  dissolved  by  the  process  of  maceration.  If  the 
foetus  be  more  mature,  its  general  form  and  the  outline  of  its  organs 
are  preserved,  but  granular  degeneration  and  disintegration  of  their 
anatomical  elements  are  everywhere  present.  The  ejiidermis  is  first 
affected  by  the  process  of  maceration.  It  is  separated  from  the  corium 
by  the  formation  of  vesicles  similar  to  those  of  pemphigus,  which  con- 
tain either  a  reddish,  sero-sanguinolent,  or  a  clear  serous  fluid.  The 
corium  is  infiltrated  with  the  same  fluid,  and  presents  the  appearance 
of  brownish-red  macerated  parchment.  The  subcutaneous  areolar  and 
adipose  tissues  are  reddish  and  redematous.  The  oedema  is  most  ap- 
parent over  the  cranium,  the  abdomen,  the  feet,  hands,  and  sternum. 
The  entire  body  is  flaccid,  and  assumes,  under  the  influence  of  external 
pressure,  curiously  distorted  shapes,  being  distended  at  some  jioints 
and  depressed  or  flattened  at  others.  The  cranial  sutures  are  separated, 
the  joints  are  disarticulated,  and  the  periosteum  has  become  detached 
from  the  long  bones.  The  vessels  are  filled  with  dark,  grumous  blood. 
The  serous  cavities  are  distended  with  bloody  serum.  The  brain  is 
transformed  into  a  grayish-red  pulp.  All  the  viscera  are  infiltrated  and 
friable,  the  uterus  and  lungs  preserving  their  normal  consistence  longer 
than  the  other  organs.  Pigment  masses  and  fat-crystals  are  deposited 
in  many  organs.  In  rare  instances  the  fetal  organs  become  covered 
with  a  greasy  substance  composed  of  cholesterin  and  the  margarates  of 
soda,  potassa,  and  lime.  These  saponified  products  are  sometimes 
termed,   collectively,    advpocere.      No  trustworthy   inferences   can   be 


DISEASES   OF   THE   OVUM.  305 

drawn  from  the  appearance  of  macerated  foetuses  as  to  the  cause  of 
their  decease,  since  the  gross  pathological  conditions  are  identical 
under  all  circumstances.*  Apparent  variations  are  duo  to  the  respect- 
ive periods  of  retention.  The  rapidity  with  which  the  process  of 
maceration  occurs  is  variable,  and  its  extent  is  therefore  no  criterion 
of  the  time  at  which  the  fetal  demise  took  place. 

Seventy-five  per  cent  of  macerated  foetuses  are  expelled,  according 
to  Ruge,f  before  the  thirty-first  week,  and  transverse  or  breech-pres- 
entations occur  in  nearly  one  half  of  all  the  cases. 

The  term  missed  labor  was  applied  by  Oldham  to  those  cases  in 
which,  the  uterine  expulsive  efforts  having  been  ineffectually  made  at 
full  term  without  other  result  than  the  escape  of  the  waters,  the 
uterine  contractions  finally  subside,  leaving  the  foetus  in  utero.  The 
causes  of  missed  labor  usually  cited  are  abnormal  absence  of  uterine 
irritability,  or  of  that  residing  in  the  reflex  nervous  centers,  obstructed 
labor,  and  unusually  close  adhesions  of  the  placenta. 

Note. — The  occurrence  of  missed  labor  has  recently  been  disputed  by  Muller 
(De  la  grossesse  uterine  prolongee  indefiniment,  Paris,  1878),  who  would  refer  all 
such  cases  to  gestations  occurring  external  to  the  uterine  cavity.  Certainly  the 
criticisms  of  Miiller  have  greatly  restricted  the  number  of  cases  which  formerly 
were  unquestionably  assigned  to  this  category.  In  certain  of  them  the  foetus  ap- 
pears secondarily  to  have  made  its  way  into  the  uterus  through  a  communicating  pas- 
sage, while  in  others  the  pregnancy  may  have  been  primarily  of  tubo-uterine  or  of 
mural  origin.  Still,  Barnes  has  since  related  the  history  of  a  case  (On  the  so-called 
"  Missed  Labor,"  Obst.  Trans.,  vol.  xxiii,  p.  81)  which  affords  strong  affirmative 
evidence  of  the  possibility  of  the  prolonged  retention  of  a  foetus  dying  before  the 
end  of  gestation  was  reached.     The  circumstances  were  briefly  as  follows :   Mrs. 

B ,  aged  thirty-nine,  had  borne  three  stillborn  children.    Five  years  later,  m  the 

month  of  October,  the  catamenia  ceased.  The  movements  of  the  child  were  felt 
between  the  third  and  fourth  months.  Between  the  eighth  and  ninth  months  there 
was  a  flow  of  blood  from  the  vagina,  which,  however,  ceased  in  a  few  days  under 
the  use  of  cold  and  styptics.  At  the  end  of  three  weeks  the  bleeding  returned,  but 
became  lighter  at  the  end  of  a  week,  and  then  gradually  disappeared.  At  no  time 
were  there  labor  pains.  At  the  end  of  January  pieces  of  bone  began  to  come  away, 
and  portions  of  bone  were  removed  by  the  finger  and  forceps  after  partial  dilatation 
of  the  cervix.  In  Febriiary,  under  chloroform,  Dr.  Barnes  proceeded  to  empty  the 
uterus.  As  the  hand  could  not  be  got  through  the  uterus.  Dr.  Barnes  extracted 
the  foetus  with  his  craniotomy  forceps.  The  foetus  was  a  compressed  mass,  bones 
emerging  in  the  surface,  the  fleshy  part  greasy,  soft,  and  putrid.  It  presented  the 
appearance  of  having  reached  the  eighth  or  ninth  month  of  gestation.  The  patient 
showed  considerable  shock  after  the  operation,  but  rallied  the  next  day,  and  eventu- 
ally recovered.  Dr.  Barnes  was  convinced,  not  only  by  examinations  made  during 
the  extraction  of  the  foetus,  but  by  the  subsequent  daily  introduction  of  the  sound, 
that  the  cavity  was  continuous  with  the  cervix,  and  that  the  dense  wall  felt  in  no 
respect  differed  from  the  characters  of  uterine  wall.  To  his  mind,  even  a  post- 
mortem examination  could  hardly  have  made  the  case  clearer.  In  the  discussion 
which  followed  Dr.  Barnes's  report  it  was,  however,  suggested  by  Sir  Spencer  Wells 
and  others  that  the  case  was  really  one  of  mural  pregnancy. 

*  RuGE,  Zeit.  f.  Geb.  u.  Gyn.,  Bd.  i,  Deft  1,  1877,  p.  58.  t  l^i^-^  P-  "^O- 

20 


306 


THE  PATHOLOGY  OF  PREGNANCY. 


Dr.  Stanley  P.  Warren,  of  Portland,  Maine,  sends  me  the  following  histotf, 
which  seems  conclusive :  The  patient  menstruated  last  in  January,  1884.  In  the 
following  May  she  was  attacked  with  general  peritonitis.  The  28th  of  October  was 
computed  as  the  probable  terminus  of  gestation.  At  that  time  continuous  cramp- 
like pains  were  felt  by  the  patient.  The  presentation  of  the  child  was  transverse. 
The  cervix  was  not  reached.  For  several  days  the  pains  recurred  at  night.  By 
the  second  week  in  November  it  was  ascertained  that  the  child  was  dead.  There 
was  no  further  expulsive  action.  On  December  30th,  after  vain  attempts  at  dilata- 
tion of  the  cervix,  Caesarean  section  was  performed,  and  a  female  child,  weighing 
eight  and  a  half  pounds,  was  removed  from  the  uterine  cavity.  The  patient  died 
from  shock  twenty-eight  hours  after  the  operation. 

According  to  Kiichenmeister  (Ueber  Lithopadien,  Arch.  f.  Gynaek.,  vol.  xvii,  p, 
153),  retention  may  result  from  obstruction  due  to  hardening  of  the  cervix,  to  car- 
cinoma, to  fibroids  in  the  lower  segment,  and  where  pregnancy  takes  place  in  the 
rudimentary  cornu  of  a  one-horned  uterus.  Retention  due  to  obliteration  of  the 
cervical  canal  he  rejects ;  but  I  have  witnessed  three  cases  of  complete  occlusion  of 
the  vaginal  vault,  where  it  was  necessary  to  dissect  up  a  long  passage  to  permit  the 
birth  of  the  child,  and  where,  without  artificial  aid,  either  rupture  of  the  uterus  or 
retention  of  the  child  must  have  resulted. 

The  pathological  processes  presenting  themselves  in  case  of  long- 
continued  retention  and  of  missed  labor  vary  with  the  entrance  of  air 
into  or  exclusion  of  air  from  the  uterine  cavity.  If  the  atmosphere 
have  free  access  to  the  uterus,  the  foetus  undergoes  putrefactive 
changes.  The  soft  parts,  having  been  liquefied,  escape,  leaving  the 
osseous  framework  of  the  fretus  in  ntero.  This  may  also  be  gradually 
and  partially  disintegrated,  liquefied,  and  expelled,  but  its  complete 
evacuation  is  not  often  effected  by  Nature's  processes.  If,  however, 
the  cervix  be  narrow  or  unyielding,  the  continuous  pressure  of  some 
projecting  and  pointed  bone  may  penetrate  its  tissues  and  force  an 
exit  through  the  vagina,  rectum,  or  anterior  abdominal  wall.  A  similar 
irritation  and  penetration  may  induce  supptirative  metritis,  and,  event- 
ually, fatal  peritonitis,  or  septicsemia. 

If  the  air  be  excluded  from  the  uterus  in  cases  of  retention  indefi- 
nitely prolonged,  the  foetus  either  becomes  mummified,  and,  forming 
intimate  connections  with  the  uterus  through  the  medium  of  inflam- 
matory products,  remains  in  ntero  ^v\i\\o\\i  giving  rise  to  any  symp- 
toms, or  it  may  produce  by  constant  irritation  suppurative  metritis, 
with  abscess  formation  and  the  escape  of  pus  externally.  Access  hav- 
ing been  thus  afforded  to  the  air,  putrefaction  and  its  consequences 
will  then  ensue. 

In  rare  cases  of  prolonged  retention,  the  foetus  becomes  the  seat  of 
adipocerous  changes.*  Calcification  of  the  foetus  (lithopaedion  forma- 
tion) occurs  probably  in  cases  of  extra-uterine  pregnancy  only. 

The  retention  of  the  dead  foetus  is  comparatively  devoid  of  danger. 
Even  if  decomposition  or  putrefaction  of  the  foetus  occurs,  it  is 
common  for  the  products  of  disintegration  to  be  eventually  eliminated, 

*  Vide  Case  of  Professor  T.  G.  Thomas,  N.  Y.  Med.  Journal,  vol.  xxi,  p.  163. 


THE   PREMATURE  EXPULSION   OF  THE   OVUM.  397 

without  a  fatal  result,  by  natural  efforts  or  by  the  intervention  of  ob- 
stetrical art.  There  is  good  evidence,  however,  that  the  dead  fa^tus 
may,  even  if  the  access  of  air  has  been  prevented,  seriously  impair  the 
patient's  health.  Lately  I  have  witnessed  the  development  of  albu- 
minuria subsequent  to  the  death  of  the  foetus,  which  disappeared  upon 
the  induction  of  premature  labor.* 

Unless,  therefore,  labor  sets  in  within  two  or  three  weeks  after  the 
death  of  the  foetus,  the  induction  of  labor  is  indicated.  The  excep- 
tion to  this  rule  would  be  in  cases  of  twin  pregnancy,  where  one  foetus 
was  still  living.  In  prolonged  retention,  the  elimination  of  pieces  of 
bone  should,  as  far  as  possible,  be  aided  by  the  hand.  If  necessary  to 
dilate  the  cervix,  care  should  be  taken  lest  spiculae  of  bone  be  pressed 
by  the  expanding  body  into  the  uterine  tissues.  Every  precaution 
should  be  taken  subsequently  to  render  the  uterine  cavity  aseptic. 
When  the  Csesarean  section  is  performed  and  the  uterine  tissues  are 
found  extensively  infiltrated,  it  has  been  suggested  that  the  Porro 
operation  may  diminish  the  risks  of  infection.  The  efficacy  of  the 
measure  would  of  course  depend  upon  the  freedom  of  the  parametria 
from  septic  invasion. 


CHAPTER   XVL 

THE  PREMATURE  EXPULSION  OF  THE  OVUM. 

Causes  of  abortion. — Disposition  to  abortion. — Immediate  causes. — Symptoms. — 
Moles. — Incomplete  abortions. — Diagnosis. — Prognosis. — Treatment. — Prophy- 
laxis.— Arrest  of  threatened  abortion. — Treatment  of  inevitable  abortion. — 
Treatment  of  neglected  abortion. — Removal  of  fibrinous  polypi. — Treatment  of 
miscarriage. 

Whex  pregnancy  is  interrupted,  during  the  first  three  months,  by 
uterine  contractions  leading  to  the  expulsion  of  the  ovum,  the  term 
abortion  is  used ;  in  the  fourth,  fifth,  sixth,  and  seventh  months — i.  e., 
from  the  formation  of  the  placenta  to  the  time  the  child  becomes 
viable — it  is  proper  to  speak  of  the  accident  as  immature  delivery,  or 
miscarriage ;  and,  finally,  a  confinement  occurring  from  the  twenty- 
eighth  week,  the  earliest  period  of  viability,  to  the  thirty-eighth  week, 
when  the  fcetus  possesses  every  indication  of  maturity,  is  distinguished 
as  premature  delivery. 

This  purely  artificial  division  is  justified  by  praerieal  differences 
in  the  symptomatology  and  treatment  of  the  groups  thus  separately 
designated. 

*  Vide  also  Barker,  On  Puerperal   Disease,  p.  402.     KEMtiJR,  Retention  «• 
Utero  of  the  Dead  Fcetus.  Trans.  Iiid.  State  Med.  Soc,  1875. 


308 


THE  PATHOLOGY  OF   PREGNANCY 


Causes  which  lead  to  the  Peematuke  Interruption  of 

Pregnancy. 

The  underlying  causes  of  abortion,  miscarriage,  and  premature 
delivery  are  the  same.  Causes  of  abortion  are  rarely  of  sudden  occur- 
rence. Usually  the  way  is  prepared,  either  by  changes  taking  place 
in  the  ovum,  or  by  certain  pathological  conditions  affecting  the 
mother.  In  either  of  these  ways  a  disposition  to  abortion  is  produced. 
When  once,  as  the  result  of  morbid  changes,  the  attachment  of  the 
ovum  to  the  uterus  has  been  rendered  insecure,  causes  usually  inopera- 
tive suffice  to  determine  uterine  contractions  and  the  time  at  which  the 
expulsion  takes  place. 

The  Disposition  to  Abortion.— The  disposition  may  be  due  prima- 
rily to  any  disease  of  the  chorion,  of  which  we  have  an  example  in 
syphilitic  degeneration  of  the  villi.  In  most  cases,  however,  death  of 
the  foetus  precedes  and  leads  to  disease  of  the  chorion.  The  causes  of 
abortion  resolve  themselves,  therefore,  in  large  measure,  into  the  causes 
which  produce  death  of  the  foetus. 

The  death  of  the  foetus  may  be  due  to  direct  violence,  as  kicks  and 
blows  upon  the  abdominal  walls  ;  to  diseases  of  the  fetal  appendages 
(cord,  amnion,  chorion,  placenta)  ;  to  diseases  of  the  decidua,  especially 
those  which  give  rise  to  haemorrhage  (before  the  complete  formation 
of  the  placenta,  the  separation  of  the  decidua  from  the  uterus  inter- 
feres with  the  nutritive  supplies  which  go  to  the  foetus)  ;  to  febrile 
affections,  in  which  death  results  either  from  the  high  temperature, 
from  associated  diseased  conditions  of  the  decidua,  or,  as  in  certain 
acute  infectious  diseases,  to  the  direct  transfer  of  the  poison  from  the 
mother  to  the  foetus ;  and,  finally,  to  excessive  anaemia.  Anaemia  de- 
veloped by  pregnancy  rarely  affects  the  child.  In  acute  anaemia  from 
profuse  hajmorrhage,  the  child  may  die  from  asphyxia.  In  times  of 
famine  great  numbers  of  women  abort.  The  disposition  to  abort  ob- 
served in  corpulent  women  is  probably  due  to  the  fact  that  the  blood 
is  insufficient  in  quantity  and  quality  to  supply  the  wants  of  the 
growing  child. 

The  death  of  the  foetus  is  followed  by  the  expulsion  of  the  ovum, 
not  usually  at  once,  but  after  a  longer  or  shorter  period  of  time.  Be- 
fore the  third  month,  in  such  cases  of  delay,  the  embryo,  which  con- 
sists of  hardly  more  than  a  heap  of  cells,  may  become  macerated,  and 
absorption  may  take  jjlace  after  the  death  of  the  embryo.  Except  in 
cases  of  hydramnion,  partial  collapse  of  the  ovum  ensues.  As  soon  as 
the  foetus  dies,  the  circulation  which  passes  from  the  foetus  to  the  cho- 
rion and  placenta  is  suspended.  The  villi  then  become  obliterated, 
and  undergo  fatty  degeneration.  The  decidua  is  affected  by  the  same 
process.  With  the  diminution  in  the  volume  of  the  ovum,  contrac- 
tions begin.     The  villi,  loosened  in  their  attachments  to  the  decidua, 


THE   PREMATURE  EXPULSION   OF  THE  OVUM.  309 

are  drawn  out,  and  the  decidual  vessels,  exposed  and  subjected  to  in- 
creased pressure,  rupture,  and  haemorrhage  results.  The  uterine  con- 
tractions are  awakened  and  exercise  an  expulsive  force  upon  the  ovum, 
which  in  its  descent  expands  the  cervix  from  above  downward,  and 
passes  finally  into  the  vagina.  In  the  first  three  months  the  ovum 
is  not  infrequently  expelled  with  membranes  unruptured.  From  the 
end  of  the  third  month  onward  such  an  occurrence  is  rare,  though  I 
have  seen  an  instance  which  happened  in  the  sixth  month.  In  the 
early  months  the  expulsion  of  an  intact  ovum  is  associated  with  in- 
considerable haemorrhage.  When  the  membranes  give  way,  the  em- 
bryo and  the  fluid  contents  of  the  amnion  escape  first.  With  the 
removal  of  the  compression  exercised  by  the  ovum  upon  the  inner 
surface  of  the  uterine  walls,  haemorrhage  occurs,  which  continues,  as 
a  rule,  nntil  the  complete  expulsion  or  removal  of  the  membranes  and 
placenta. 

Aside  from  the  death  of  the  foetus,  with  consecutive  changes  in 
the  chorion  and  decidua,  and  diseases  of  the  fetal  appendages  leading 
to  death  of  the  foetus,  the  predisposition  to  abortion  may  be  the  result 
of  primary  defects  or  changes  in  the  decidua  alone.  Of  these  changes 
w^e  recognize  : 

1.  Atrophy  of  the  Uterine  Mucous  Membrane. — The  insufficient 
development  of  the  mucous  membrane  exercises  an  injurious  influence 
uj^on  the  development  of  the 
ovum  in  cases  only  in  which  the 
serotina  and  the  reflexa  are  in- 
volved. An  abnormally  small 
and  undeveloped  serotinal  sur- 
face may  give  rise  to  a  small  pla- 
centa, or  the  serotinal  attach- 
ment may  be  of  such  limited  ex- 
tent that  the  mere  weight  of  the 
ovum  drags  it  downward  and 
converts  it  into  a  long,  narrow 

,.   .  1,       ,1  !_■  ,^  Fig.  135.— Ovum,  with  imperfectly  developed 

pedicle.       At  other  times,  the  re-  decidua  ;  outer  surface  of  vera.    (Duncan.) 

flexa  may  be  but  partially  devel- 
oped, or  may  fail  altogether,  and  then  the  ovum,  covered  only  by  the 
chorion,  hangs  by  a  pediculated  attachment  to  the  serotina. 

In  both  these  cases  the  uterine  contractions,  instead  of  at  once 
effecting  the  expulsion  of  the  ovum,  may  force  the  ovum  into  the 
cervix,  where  it  may  remain  for  a  time,  nourished  by  the  long  pedicle, 
but  arrested  in  its  further  descent  by  a  contracted  os  externum.  To 
these  cases  the  term  cervical  pregnancy  has  been  applied.  The  cervix, 
according  to  the  month  of  pregnancy,  is  more  or  less  spherically  dis- 
tended, and  the  corpus  uteri  above  contracts  down  to  nearly  normal 
dimensions.     As  the  cause  of  this  condition  lies  chiefly  in  rigidity  of 


310  THE   PATHOLOGY   OF   PREGNANCY. 

the  OS  externum,  it  occurs  most  frequently  in  primipara.  Even  with 
a  patulous  os,  though  rarely,  a  cervical  pregnancy  may  be  produced  by 
the  resistance  and  firmness  of  the  pedicle  attaching  the  ovum  to  the 

uterus.* 

2.  Hypertroi)liy  of  the  Mucous  Membrane.— Thickening  of  the  mu- . 
cous  membrane  is  the  result  of  endometritis,  and  may  lead  to  abortion 
in  either  of  the  following  ways:  The  several  forms  of  endometritis 
may  give  rise  to  affections  of  the  placenta,  and  thus  prove  fatal  to  the 
foetus,  or  the  thinned,  dilated  vessels  of  the  diseased  decidua  may 
rupture,  and  produce  sanguineous  effusions  between  the  membranes. 

The  frequency  of  abortion  in  displacements  of  the  uterus  is  prin- 
cipally dependent  upon  associated  endometritis.  In  anteflexion  of  the 
uterus,  sterility  is  common,  but  endometritis  and  abortion  are  rare. 
In  retroflexion,  on  the  contrary,  while  there  is  slight  obstacle  to  con- 
ception, the  congestion  of  the  uterine  walls  and  the  altered  conditions 
of  the  uterine  mucous  membrane  render  abortion  a  frequent  occur- 
rence. 

Eigidity  of  the  uterine  walls,  which  interferes  Avith  their  due  ex- 
pansion, may  lead  to  premature  uterine  contractions.  In  "this  way  an 
imbedded  flbroid  or  carcinoma  may  ultimately  become  sources  of  abor- 
tion. Expansion  of  the  uterus  may  likewise  be  hindered  by  old  peri- 
toneal adhesions  or  pelvic  cellulitis. 

•  Finally,  there  remains  a  class  of  women  in  whose  cases  it  is  impos- 
sible to  detect  either  disease  of  the  ovum  or  of  the  genital  organs,  yet 
in  whom  abortion  occurs,  dependent,  so  far  as  our  present  knowledge 
•goes,  upon  certain  personal  conditions  of  nerve  irritability.  Physical 
and  psychical  sources  of  excitement  which  would  be  of  small  moment 
in  some  women,  in  them  suffice  to  interrupt  pregnancy. 

Immediate  Causes  of  Abortion. — Changes  in  the  ovum  other  than 
rupture  and  escape  of  the  amniotic  fluid  rarely  lead  at  once  and  di- 
rectly to  abortion.  The  proximate  causes  which  induce  contractions 
and  the  throwing  off  of  the  ovum  reside  for  the  most  part  in  the  ma- 
ternal system.     They  consist  of  : 

1.  Hypercemia  of  the  Gravid  Uterus. — When  the  predisposing 
causes  have  operated  to  weaken  the  attachments  of  the  ovum  to  the 
decidua,  anything  which  determines  the  blood-currents  to  the  uterus  is 
liable  to  produce  extravasations  of  blood  around  the  ovum,  and  awaken 
uterine  contractions.  Because  of  this  fact,  we  surround  patients  pre- 
disposed to  abort  with  every  precaution  during  the  periodic  menstrual 
congestion  that  not  even  pregnancy  altogether  suspends.  Fevers,  in- 
flammatory affections  of  the  genital  organs,  excesses  in  coitus,  hot 
foot-baths,  valvular  heart  lesions,  obstructions  to  the  circulation  of  the 
lungs   and   liver,  may  each  lead  to  rupture  of  the  decidual   vessels. 

*  W.  ScHULEix,  Ueber  cervicale  Schwangerschaft,  Ztschr.  f.  Geburtsh.  und  Gy- 
naek.,  Bd.  iii,  H.  2,  p.  408. 


THE   PREMATURE   EXPULSION   OF  THE   OVUM.  3H 

More  frequently  rupture  follows  jars  to  the  body  from  vomiting,  cough- 
ing, and  straining,  from  railroad  journeys,  from  violent  exercise,  from 
falls,  and  the  like. 

The  importance  of  separating  the  predisposing  from  the  immediate 
causes  of  abortion  is  shown  by  the  impunity  with  which  often  i)er- 
fectly  healthy  women,  with  no  abnormal  conditions  of  the  generative 
organs,  set  all  the  usual  restraints  at  defiance  with  the  intent  to  inter- 
rupt an  undesired  pregnancy.  M.  Brillaud  Laujardiere  relates  the 
case  of  a  peasant  who  took  his  wife,  while  e)iceinte,  behind  him  on 
horseback,  and  started  off  with  her  at  full  gallop  with  the  view  of  caus- 
ing her  to  miscarry.  Having  thus  thoroughly  shaken  her,  he  dropped 
her  suddenly  to  the  ground  Avithout  slackening  his  speed.  This  brutal 
manoeuvre  he  repeated  twice  without  the  least  success.*  On  the  other 
hand,  women  eager  for  offspring,  after  an  abortion,  sometimes  lay 
undue  stress  upon  slight  imprudences,  and  make  them  the  sources  of 
morbid  self-reproaches,  which  it  becomes  one  of  the  functions  of  the 
physician  to  allay. 

2.  Uterine  Contractions  jiroduced  hy  Influences  tohich  act  directly 
through  the  Nerves. — Of  this  we  have  examples  in  the  contractions 
awakened  by  frictions  of  the  uterus  through  the  abdominal  walls,  in 
the  reflex  contractions  j^roduced  by  stimuli  applied  to  the  breasts,  and 
in  those  excited  by  strong  mental  emotions. 

Symptoms. — As  the  detachment  and  expulsion  of  the  ovum  can  not 
possibly  take  place  without  rupture  of  the  decidual  or  placental  ves- 
sels, haemorrhage  becomes  the  constant  and  necessary  result  of  every 
abortion.  In  the  first  two  months  the  haemorrhage  resembles  that  of 
a  profuse  menstruation.  Pain  is  present,  in  part  due  to  uterine  con- 
gestion, in  part  to  the  expulsion  of  blood-clots  through  the  imperfectly 
expanded  cervix.  The  latter  pains  resemble  those  of  obstructive  dys- 
menorrhoea.  These  symptoms  last  from  four  to  five  days.  As  the 
ovum  passes  away  unnoticed,  enveloped  in  the  clots,  or  piecemeal 
with  the  decidua,  women  are  apt  to  regard  these  early  abortions  as  the 
normal  recurrence  of  a  retarded  menstrual  jieriod. 

After  the  second  month  prodromal  symptoms  are  rarely  wanting. 
Among  these  may  be  mentioned  fullness  and  weight  in  the  pelvis,  sa- 
cral pains,  frequent  micturition,  periodic  labor-like  pains,  and  a  mu- 
cous or  watery  discharge.  These,  followed  by  haemorrhage,  indicate  a 
threatened  abortion.  The  hwmorrhago.  if  slight,  may  cease,  and  the 
pregnancy  go  on  undisturbed.  Usually,  however,  the  haemorrhage 
increases  in  amount,  or  after  a  brief  cessation  recurs.  Contractions 
set  in,  which  become  more  and  more  pronounced,  until  finally  the 
ovum  is  expelled. 

In  a  typical  case  of  abortion,  in  which  the  ovum  is  thrown  off 
entire,  uterine  retraction  and  haemorrhage  unite  to  effect  the  progress- 

*  T.  GrALLARD,  De  ravortement  an  i)oint  de  vue  iiuHlieo-legal,  Paris,  p.  24. 


312  THE  PATHOLOGY  OF  PRE&NAXCY. 

ive  separation  from  below  upward  of  the  decidiia  from  the  uterine 
walls.  The  ovum  then,  covered  by  the  refiexa  and  the  detached  de- 
cidua,  is  gradually  pressed  downward,  and  dilates  first  the  os  internum, 
next  the  cervix,  and  finally  the  os  externum.  The  ovum  passes  into 
the  vagina,  covered  by  the  decidua  vera,  or  drags  the  inverted  decidua 
after  it.  The  emptied  uterus  then  retracts  down,  and  the  hemorrhage 
ceases.  The  aborted  ovum  is  surrounded  with  coagulated  blood.  In 
the  first  three  months,  when  the  death  of  the  embryo  has  preceded  by 
a  little  time  the  completion  of  the  abortion,  every  vestige  of  the  em- 
bryo may  be  found  to  have  disappeared.  Sometimes,  in  the  third 
month,  a  small  placenta  with  shrunken  umbilical  vessels  may  now  and 
then  be  met  with. 

When  the  extravasation  of  blood  upon  the  uterine  surface  of  the 
vera  is  considerable  in  amount,  the  vera  is  sometimes  broken  through, 
and  the  blood  effused  between  the  vera  and  reflexa.  Extravasation 
may  likewise  take  place  between  the  reflexa  and  chorion,  either  in 
consequence  of  the  rupture  of  the  reflexa,  or  from  a  haemorrhage  start- 
ing from  the  placenta,  which  finds  its  way  along  the  Outer  surface  of 
the  chorion,  and  dissects  away  the  reflexa.  The  pressure  upon  the 
ovum,  unless  it  has  joreviously  undergone  collapse  as  a  result  of  the 
death  of  the  embryo,  leads  to  rupture  and  escape  of  the  amniotic  fluid. 
The  retained  fetal  and  maternal  membranes,  with  the  intervening  lay- 
ers of  coagulated  blood,  form  a  mass  termed  a  mole.  When  the  blood 
coagula  are  fresh,  the  mass  is  termed  the  mola  mngiiinea  (blood-mole), 
and  when  of  older  date  the  mola  carnosa  (flesliy  mole).  The  cavity, 
which  is  lined  by  the  amnion,  has  usually  an  irregular  surface.  It  is 
very  exceptional  for  extravasations  to  break  through  both  chorion  and 
amnion,  and  thus  form  clots  in  tlie  amniotic  cavity  itself.  Moles  sel- 
dom exceed  an  orange  in  size,  and  usually  are  expelled  between  the 
third  and  fifth  month. 

In  cases  where  abnormal  adhesions  attach  the  vera  and  serotina  to 
the  walls  of  the  uterus,  retained  portions  of  the  maternal  membranes 
may  remain  after  the  ovum  is  expelled.  In  another  class — and  this  is 
the  rule  after  the  third  month — the  fetal  membranes  rupture,  and  the 
embryo  escapes  with  the  liquor  amnii.  While  ordinarily  the  retained 
portions  quickly  follow  the  discharge  of  the  ovum  or  embryo,  it  fre- 
quently happens  that  the  uterus  retracts  upon  its  contents,  the  cervix 
closes,  and  a  period  of  repose  follows.  There  is  then  produced  what  is 
commonly  known  as  an  incomplete  abortion. 

Incomplete  Abortion. — The  various  contingencies  arising  from  these 
cases  of  incomplete  abortion  are  thus  truthfully  depicted  by  Spiegel- 
berg  :  * 

1.  Most  frequently  haemorrhage  continues  at  intervals,  spontaneous 
elimination  gradually  taking  place  as,  through  retrograde  changes,  por- 
*  Spiegelberg,  Lehrbuch  der  Geburtshulfe,  Jahr.,  1877,  p,  377. 


TUE   PREMATURE  EXPUI.SION  OP  THE   OVUM.  513 

tions  of  tlie  retained  membranes  become  successively  loosened  in  their 
attachments  to  the  uterus. 

2.  In  exceptional  cases  the  hemorrhage  ceases  for  a  time  entirely. 
For  days,  weeks,  and  even  months,  the  woman  appears  quite  well. 
Then  suddenly  strong  contractions,  accompanied  by  profuse  hfemor- 
rhage,  usher  in  the  elimination  of  the  fetal  dependencies.  In  a  case 
of  my  own,  three  months  elapsed  from  the  occurrence  of  the  first 
haemorrhage,  which  took  place  toward  tlie  end  of  the  third  month, 
and  was  quite  insignificant  in  amount,  before  the  abortioii  was  com- 
pleted. Meantime,  as  there  were  progressive  abdominal  enlargement, 
supposed  quickening,  and  milk  in  the  breasts,  the  threatened  abortion 
was  believed  to  have  been  arrested.  Total  retention,  with  a  long  in- 
terval of  repose,  is  thought  to  be  due  to  complete  adherence  of  the 
l^lacenta,  which  continues  to  receive  nutrient  supplies  from  the  uterus. 
Spiegelberg  believes  that  a  menstrual  period  is  the  usual  time  at  which 
the  discharge  of  the  retained  membranes  takes  place. 

3.  Of  more  frequent  occurrence  than  the  foregoing  is  the  putrid 
decomposition  of  the  retained  portions.  It  occurs  chiefly  in  cases 
where  there  is  more  or  less  complete  loss  of  organic  connection  between 
the  placenta  and  the  uterus.  Decomposition  in  the  non-adherent  por- 
tions is  produced  by  the  introduction  of  air  during  the  escape  of  the 
embryo,  or  through  the  subsequent  passage  of  the  finger  into  the  ute- 
rus, or,  where  portions  of  the  ovum  hang  down  into  the  vagina,  by 
absorption  of  septic  matter  from  the  vagina  upward  into  the  uterus. 
As  a  result  of  putrid  decomposition,  the  woman  is  exposed  to  septicae- 
mia, and  infection  of  thrombi  at  the  placental  site.  Fatal  results  are, 
however,  rare,  as  decomposition  is  usually  a  late  occurrence,  setting  in, 
as  a  rule,  only  after  protective  granulations  have  formed  upon  the 
uterine  miicous  membrane,  and  after  the  complete  closure  of  the  uter- 
ine sinuses.  Continuous  fever,  with  intercurrent  attacks  of  ha?mor- 
rhage,  is,  however,  set  up,  but  passes  away  finally  with  the  gradual  dis- 
charge of  the  decomposed  particles,  while  the  threatening  symptoms 
subside.  Still,  now  and  then  septic  processes  lead  to  an  unfavorable 
termination.     Local  perimetritic  inflammation  is  a  common  event. 

4.  Where  there  is  a  certain  degree  of  relaxation  with  enlargement 
of  the  uterine  cavity,  the  fibrin  of  the  extravasated  blood  may  become 
deposited  about  any  uneven  surface  within  the  uterus  and  give  rise  to 
a  polypus-shaped  body,  suggestive  in  its  mode  of  develojunent  of  the 
stalactite  formations  in  calcareous  caverns.*  These  so-called  iiln-inous 
polypi  generally  develop  around  the  dehri>i  of  an  abortion,  such  as 
retained  bits  of  decidua,  placental  remains,  and  portions  of  the  fetal 
membranes.  In  some  cases,  likewise,  thrombi  projecting  from  tJie 
placental  site  become  the  base  of  a  loose  fibrinous  attachment.     Pla- 

*  Frankel,  Beitrag  zur  Lehre  von  fibriniisen  Polypen,  Arch.  f.  Gynaek..  Pd.  ii, 
p.  76. 


314 


THE  PATHOLOGY  OF  PREGNANCY. 


cental  polypi  give  rise  ultimately  to  bearing-do wu  pains  and  intercur- 
rent hgemorrhages.  They  may  even  decompose,  and  endanger  life  by 
septic  absorption. 

The  retrograde  changes  that  take  place  in  a  uterus  after  an  abor- 
tion correspond  to  those  which  occur  in  deliveries  at  full  term.    Where 


Fig.  136. — Uterus,  with  basis  of  a  fibrinous  polypus  after  an  alxiriioii.    (Frankel.) 


a  suitable  plan  of  treatment  is  not  adopted,  or  where  the  importance 
of  care  in  the  after-management  is  not  adequately  appreciated,  sub- 
involution is  apt  to  follow.  Of  all  sources  of  uterine  disease,  none 
takes  precedence  of  a  mismanaged  abortion. 

Diagnosis. — The  diagnosis  is  based  upon  the  presence  of  pain, 
hgemorrhage,  dilatation  of  the  cervix,  and  the  descent  of  the  ovum. 
When  the  ovum  can  be  felt  through  the  patulous  os  the  demonstration 
is  of  course  complete.  A  soft  polypus  may,  however,  present  a  decep- 
tive resemblance  to  a  small  ovum.     In  all  eases  of  pregnancy  the  exist' 


THE  PREMATURE  EXPULSION  OB^  THE  OVUM.      ;J15 

ence  of  hfemorrhage  alone,  even  when  disassociated  from  other  symp- 
toms, renders  the  probabilities  of  abortion  sufficiently  great  to  call  for 
the  exercise  of  every  precaution.  It  is  not  easy  to  recognize  pregnancy 
in  the  early  months,  but  in  doubtful  cases  the  cessation  of  the  menses 
should  be  regarded  as  presumptive  evidence  of  its  existence. 

The  diagnosis  of  these  pathological  changes  in  the  ovum  and  de- 
cidufe  which  pave  the  way  for  abortion  can  not  be  made  out  with 
certainty  from  mere  subjective  symptoms.  Such  changes  may  be 
regarded  as  probable  Avhen  the  size  of  the  uterus  does  not  correspond 
to  the  supposed  period  of  gestation.  Thus,  if  the  uterus  at  the  lifth 
month  was  no  larger  than  is  usual  at  the  third  month,  the  death  of 
the  embryo  with  arrest  in  the  development  of  the  ovum  would  be 
naturally  inferred. 

When  the  physician  is  summoned  to  a  case  of  haemorrhage  occur- 
ring during  pregnancy,  he  should  at  once  examine  the  clots,  where 
they  have  been  preserved,  for  traces  of  the  ovum.  The  clots  should 
be  broken  up  under  water,  and  a  careful  examination  made  for  floating 
fringes  of  villi.  The  ovum,  when  expelled  entire,  is  usually  enveloped 
in  layers  of  coagulated  blood,  so  that  without  tliorough  search  it  would 
easily  pass  unnoticed.  If  the  coagula  have  been  thrown  away,  and 
the  physician  finds  upon  his  arrival  the  cervix  closed,  so  that  he  can 
not  2)ass  his  finger  into  the  uterus  to  explore  its  cavity,  it  may  be  im- 
possible at  once  to  determine  whether  the  abortion  has  taken  place 
wholly  or  in  part,  or  whether  the  entire  ovum  still  remains  in  utero. 
The  subsidence  of  all  symptoms  points,  as  a  rule,  to  a  complete  emp- 
tying of  the  uterus,  or  to  an  arrest  of  the  abortion,  though  in  some 
cases  it  precedes  mole-formation.  A  renewal  of  the  haemorrhage  and 
the  absence  of  normal  involution  indicate  the  continuance  of  the  ovum 
in  the  uterus,  or  an  incomplete  abortion. 

Prognosis. — The  prognosis  takes  cognizance,  of  course,  of  the  results 
to  the  mother  only.  In  the  first  place,  it  may  be  laid  down  in  the  way 
of  broad  general  statement,  that  all  cases  of  spontaneous  abortion  (i.  e., 
excluding  criminal  cases)  not  complicated  with  other  morbid  condi- 
tions are,  under  suitable  medical  guidance,  devoid  of  danger.  But, 
in  the  second  place,  it  must  be  borne  in  mind  that  the  statement  is 
only  true  with  the  reservations  that  limit  it,  for  in  point  of  fact  the 
actual  number  of  deaths  from  abortion  is  by  no  means  inconsiderable. 
Thus,  the  deaths  from  this  cause  reported  to  the  Bureau  of  Vital  Sta- 
tistics of  New  York  City  between  the  years  18G7  and  1875,  inclusive, 
were  one  hundred  and  ninety-seven* — a  number  which  falls  short,  in  all 
probability,  of  the  truth,  by  reason  of  the  many  circumstances  which 
precisely  in  this  condition  tempt  to  concealment.  The  total  number 
of  deaths  during  the  same  period  from  metiia  was,  according  to  the 

*  LusK,  Nature,  Origin,  and  Piovention  of  Puerjieral  Fever,  Transactions  of  the 
International  Medical  Congress,  Philadelphia,  p.  8oO. 


316  THE   PATHOLOGY   OF   PREGNANCY. 

reports  rendered,  1,947.  Hegar  *  reckons  one  ubortiou  to  every  eight 
to  ten  full-time  deliveries.  If  this  proportion  be  correct,  it  would 
seem  to  show  that  the  mortality  from  abortion  is  hardly  second  to  that 
from  puerperal  fever  itself. 

Death,  as  a  consequence  of  criminal  abortion,  is  especially.frequent. 
M.  Tardieu  found  that  in  one  hundred  and  sixteen  such  cases  of  which 
he  was  able  to  ascertain  the  termination,  sixty  women  died.f  But  even 
in  spontaneous  cases  death  may  take  place  from  hemorrhage,  from  sep- 
ticemia, or  from  peritonitis.  In  many  instances  the  fatal  termination 
is  fairly  attributable  to  the  ignorance,  the  imprudence,  or  the  willful- 
ness of  the  patient.  How  far  the  dangers  of  abortion  may  be  neutral- 
ized by  proper  medical  assistance  is  best  shown  by  the  statistics  of 
large  hospitals.  Thus,  I  gather  from  the  reports  issued  by  Dr.  John- 
ston during  his  seven  years' mastership  of  the  Kotuuda  Hospital,  in. 
Dublin,  that  in  two  hundred  and  thirty-four  cases  of  abortion  treated 
in  that  institution  there  was  but  one  death,  and  that  not  from  puer- 
peral trouble,  but  from  mitral  disease  of  the  heart.  Bellevue  Hospital 
is  the  receptacle  annually  of  a  tolerably  large  number  of  women  suffer- 
ing from  incomplete  abortions,  many  of  whom  enter  the  hospital  in  a 
very  unpromising  condition  from  either  excessive  hemorrhage  or  septic 
decomposition  of  the  retained  portions  of  the  ovum.  Yet,  of  the  many 
patients  whose  histories  I  find  in  the  record-books  of  the  hospital  since 
it  has  been  customary  to  clear  out  the  uterus  in  every  case  of  incom- 
plete abortion,  all  have  recovered. 

Treatment. — The  treatment  is  divided  into — 1.  Prophylaxis  in  cases 
of  habitual  abortion ;  2.  Arrest  of  threatened  abortion ;  3.  Means 
adopted  to  avert  the  dangers  of  a  progressing  abortion. 

Prophylaxis. — Prophylaxis  considers  the  cause  which  underlies,  in 
each  case,  the  disposition  to  repeated  abortion.  One  of  the  principal 
of  these  causes  is  syphilis  in  one  or  both  parents.  It  is  just  in  these 
cases  that  the  triumph  of  the  mercurial  treatment  has  been  most  com- 
plete. The  treatment  should  be  addressed  to  the  parent  affected,  or 
both  parents  should  be  subjected  to  the  same  treatment. 

Among  local  conditions  amenable  to  treatment  may  be  mentioned 
endometritis,  displacements,  and  perimetritic  inflammations.  In  re- 
troflexions and  retroversions,  the  best  results  often  follow  the  rephu^e- 
ment  of  the  uterus  and  the  employment  of  a  suitable  pessary.  Xo 
harm  results  from  the  use  of  pessaries  during  pregnancy.  They  should, 
however,  be  watched,  on  account  of  possible  vaginal  irritation.  After 
the  completion  of  the  third  month  they  should  be  removed,  as  the 
uterus  then  remains  in  place  without  artificial  assistance.  When  back- 
ward displacement  of  the  uterus  follows  abortion,  reposition  aids  nor- 

*  Hegar,  Beitrage  zur  Pathologie  des  Eies,  Monatsschr.  f.  Geburtsk.,  Bd.  xxi 
(supplement),  p.  34. 

t  T.  Gallard,  De  I'avortement  au  point  de  vue  medico-legal,  Paris,  1878,  p.  45. 


THE  PREMATURE   EXPULSION   OP  THE   OVUM.  317 

mal  involution.  When  endometritis  is  secondary  to  extensive  cervical 
laceration  the  Emmet  operation  is  indicated. 

In  carcinoma  and  large  fibroids  treatment  is  powerless.  Where, 
in  such  cases,  sterility  does  not  exist,  happily  for  the  mother,  the 
associated  morbid  conditions  of  the  uterine  mucous  membrane  and 
the  rigidity  of  the  uteri ue  walls  lead  commonly  to  the  death  of  the 
ovum  and  jiremature  uterine  contractions.  Where  a  small  fibroid  in 
the  posterior  uterine  walls  leads  to  sterility  by  the  production  of  retro- 
flexion, a  pessary  may,  after  replacement,  at  times  be  used  with  benefit. 

One  abortion  sometimes  follows  another  in  rapid  succession  in 
newly  married  women.  While  the  first  abortion  may  have  been  due 
to  some  accidental  cause,  the  sequence  is  often  kept  up  by  a  morbid 
condition  of  the  endometrium,  generated  by  the  shortness  of  the  inter- 
val between  the  pregnancies,  which  does  not  allow  time  for  the  detach- 
ment of  the  decidua  and  the  restoration  of  the  membrane  to  a  normal 
condition.  In  such  cases,  curetting  is  often  of  service,  and  a  six  weeks' 
abstention  from  sexual  intercourse  may  be  usefully  enjoined. 

In  certain  diseases  of  the  placenta,  in  which  the  respiratory  func- 
tion of  the  organ  had  suffered  any  marked  diminution.  Sir  J.  Y. 
Simpson  believed  he  had  succeeded  in  averting  the  death  of  the  foetus 
by  increasing  the  oxygen  in  the  blood  of  the  mother,  through  the  ad- 
ministration of  chlorate  of  potash.*  Chlorate  of  potash  may  be  given 
in  doses  of  twenty  grains,  three  times  daily,  for  weeks  at  a  time,  with- 
out injury  to  the  mother.  Though  it  has  not  always  rendered  me  the 
hoped-for  service,  the  experience  of  other  physicians,  among  whom  I 
may  mention  Dr.  Fordyce  Barker,  appears  favorable  to  its  employ- 
ment. 

In  the  class  of  cases  in  which  abortion  results  neither  from  disease 
of  the  ovum  nor  of  the  uterus,  but  seems  dependent  upon  some  pe- 
culiar condition  of  nerve-irritability,  the  patient  should  not  oidy  avoid 
every  known  means  of  awakening  uterine  contractions,  but  should 
exercise  the  utmost  caution  at  the  recurrence  of  the  menstrual  epochs. 
Especially  at  the  terminations  of  the  second  and  third  months  a  week's 
quiet  in  bed  should  be  insisted  upon.  Dr.  E.  J.  Jenks  f  recommends 
the  viburnum  prunifolium  in  cases  where  the  habit  of  aborting  has 
been  formed.  He  writes :  "  My  mode  of  prescribing  the  viburnum  is  to 
have  the  patient  take  from  a  half-teaspoonful  to  a  teaspoonful  of  the 
fluid  extract  four  times  a  day,  beginning  at  least  two  days  before  the 
menstrual  date,  and  continuing  it  not  only  during  the  usual  period  of 
the  menstrual  flow,  but  two  days  longer  than  that  discharge  continues 
when  the  woman  is  not  pregnant."  From  the  fourth  month  onward, 
the  danger  of  the  occurrence  of  abortion  rapidly  diminishes. 

*  Sir  J.  Y.  Simpson,  Obstetric  Memoirs,  edited  by  Priestley  and  Storer,  Edin- 
burgh, 1865,  vol.  i,  p.  460. 

f  Jenks,  Viburnum  Prunifolium,  Trans,  of  the  Am.  Gyna?coI.  Soc,  vol.  i,  p.  130. 


318  THE  PATHOLOGY  OF  PREGNANCY. 

The  Arrest  of  a  Threatened  Abortion.— Arrest  may  be  accomplished 
in  cases  in  which  the  death  of  the  ovum  has  not  taken  place,  and 
where  the  haemorrhage  arises  from  a  slight  detachment  only  of  the 
decidua  or  placenta. 

In  every  case  of  threatened  abortion  occurring  in  the  early  months, 
a  careful  examination  should  be  instituted  to  ascertain  whether  retro- 
flexion or  retroversion  exists.  In  the  genu-pectoral  position,  replace- 
ment is  easy.  If  the  fundus  is  slowly  raised  by  two  fingers  introduced 
into  the  vagina,  so  soon  as  the  horizontal  line  is  reached  the  uterus 
falls  forward  of.  its  own  weight.  Replacement  alone,  in  certain  cases, 
suffices  to  relieve  the  congestion  which  furnishes  the  immediate  cause 
of  the  abortion. 

In  a  paper  read  by  Dr.  J.  A.  Dol^ris  before  the  Obstetrical  Section  of  the 
Ninth  International  Medical  Congress,  entitled  The  Treatment  and  Restoration 
of  the  Cervix  Uteri  during  Pregnancy,  that  distinguished  French  accoucheur 
advocated  the  performance  of  trachelorrhaphy  in  certain  cases  of  cervical  lac- 
eration during  pregnancy,  as  a  means  of  averting  threatened  abortion. 

The  subject  is  of  such  importance,  that  I  take  this  opportunity  of  relating 
the  following  personal  experience : 

Mrs.  X.  was  married  at  the  age  of  twenty.  Ten  months  later  she  gave  birth 
to  a  vigorous  child,  which  weighed  ten  pounds.  The  cervix  was  torn  on  the 
left  side  to  the  vaginal  junction.  Three  months  after  the  birth  of  the  first  child 
she  became  again  pregnant.  Very  early  in  pregnancy  she  had  repeated  attacks 
of  hfemorrhage,  with  continuous  sero-sanguinolent  discharges.  At  the  end  of 
six  months  she  gave  birth  to  a  child  which  lived  for  a  few  hours.  The  placenta 
was  firmly  adherent  and  was  to  a  great  extent  impaired  in  its  functions  by  the 
presence  of  white  infarctions. 

In  childbed  the  uterus  became  displaced  backward,  so  that  its  reposition 
was  necessary.  Owing  to  continued  sanguinolent  discharges,  at  the  end  of  five 
weeks  the  uterine  cavity  was  curetted.  This  was  followed  witliin  four  weeks 
by  the  symptoms  of  a  new  pregnancy.  Again  the  i)atient  had  hemorrhages, 
sero-sanguinolent  discharges,  and  intermittent  ])ains,  and  was  confined  almost 
constantly  to  her  bed.  As  she  was  earnestly  desirous  of  carrying  her  child  to 
term,  she  eagerly  accepted,  when  gestation  was  three  months  advanced,  my 
proposition  to  perfonn  Emmet's  operation.  The  result  was  immediate.  The 
pains,  the  discharges,  the  haemorrhages  ceased  as  if  by  magic.  The  patient  felt 
herself  perfectly  well,  and  at  full  term  gave  birth  to  a  girl  weighing  seven 
pounds. 

Pain  in  the  back  during  pregnancy  should  be  regarded  by  women 
as  a  warning  for  them  to  temporarily  abstain  from  their  ordinary  avo- 
cations. With  ever  so  slight  a  htemorrhage,  they  should  at  once  be 
made  to  lie  down  and  keep  perfectly  still.  Simple  turning  in  bed  may 
start  up  fresh  bleeding.  Restlessness  and  mental  excitement  should  be 
allayed  by  opiates  in  full  doses.  Ice  to  the  vulva,  cold  cloths  to  the 
abdomen,  and  the  internal  administration  of  haemostatics,  are  not  indi- 
cated. The  fluid  extract  of  viburnum  prunifolium  is  recommended 
by  Dr.  Jenks,  in  teaspoonful  ,doses  every  two  or  three  hours,  as  long 


THE  PREMATURE  EXPULSION   OP   THE   OVUM.  319 

as  its  use  seems  to  be  demanded.*  Tlie  author's  somewhat  limited 
experience  has  appeared  favorable  to  the  claims  put  forth  for  the 
viburnum  as  a  uterine  sedative.  Where  the  foregoing  measures  prove 
successful,  it  is  a  safe  rule  to  keep  the  patient  in  bed  for  a  week  after 
the  final  disappearance  of  the  threatening  symptons. 

In  cases  of  ascertained  death  of  the  foetus,  and  in  those  of  inevi- 
table abortion,  all  measures  calculated  to  retard  the  emptying  of  the 
uterus  should  be  at  once  abandoned. 

In  the  first  four  months  there  are  no  unequivocal  signs  of  the  death 
of  the  fcBtus.  From  the  middle  of  pregnancy  onward  death  may  be 
assumed,  if,  after  repeated  examinations,  the  absence  of  the  fetal  heart- 
sounds  and  fetal  movements  is  confirmed. 

The  signs  of  inevitable  abortion  are  profuse  haemorrhage,  clots  dis- 
charged from  the  uterus,  dilatation  of  the  cervix  from  the  descent  of 
the  ovum,  and  a  patulous  condition  of  the  os  externum.  Other  symp- 
toms consist  of  persistent  uterine  contractions,  escape  of  the  amniotic 
fluid,  and  the  presence  of  the  embryo  or  of  portions  of  the  ovum  in 
the  discharged  clots.  How  far  the  ordinary  signs  may  in  given  cases 
prove  delusive,  is  shown  by  a  remarkable  one  reported  by  Scanzoni,  of 
a  woman  who  was  seized  with  profuse  metrorrhagia  in  the  third  month 
of  pregnancy.  Great  numbers  of  clots  were  discharged.  As  all  hopes 
of  saving  the  ovum  were  abandoned,  ergot  was  used  in  large  doses,  a 
tampon  was  placed  in  the  vagina  for  thirty-six  hours,  a  sound  was  em- 
ployed to  explore  the  uterus,  and  finally,  as  the  bleeding  continued  for 
three  weeks,  an  intra-uterine  injection  of  a  weak  solution  of  perchloride 
of  iron  was  resorted  to.  Eight  weeks  later  the  patient  quickened,  and 
presented  the  distinctive  evidences  of  a  pregnancy  advanced  to  the 
sixth  month. f 

The  Treatment  of  Inevitable  Abortion. 

In  the  treatment  of  inevitable  abortion  it  is  proper  to  distinguish 
between  cases  of  abortion  proper  and  those  of  miscarriage.  To  avoid, 
however,  needless  repetitions,  it  is  only  points  of  distinctive  difference 
to  which,  at  the  close,  attention  will  be  directed.  The  management  of 
premature  deliveries  differs  in  no  respect  from  that  of  confinement  at 
term. 

In  the  first  two  months  little  treatment  besides  rest  in  bed  for  a 
few  days  is  ordinarily  required.  In  the  exceptional  cases  the  treat- 
ment does  not  differ  from  that  m  the  haemorrhages  of  the  non-preg- 
nant uterus. 

In  the  third  month  we  distinguish — 1.  Cases  in  wliich  the  ovum 
is  thrown  off  entire;  2.  Cases  in  which  the  sac  ruptures  and  the  em- 
bryo escapes  with  the  discharged  fluid. 

*  Jenks,  loc.  cit.,  p.  130. 

f  Scanzoni,  Lelirbuch  der  Geburtshillfe,  Wiori,  1867,  p.  83. 


320 


THE  PATHOLOGY  OF  PREGNANCY. 


1.  When  in  the  third  month  the  ovum  is  thrown  ofE  without  rupt- 
ure of  the  fetal  membranes,  the  hsemorrhage  rarely  assumes  dangerous 
proportions.  The  uterine  contractions  press  the  ovum  into  the  cervix, 
which  dilates,  and,  in  primiparse,  becomes  somewhat  elongated.  As  the 
ovum  descends,  the  body  of  the  partially  emptied  uterus  retracts.  The 
eliused  blood  coagulates  in  thin  layers  between  the  ovum  and  the  uter- 
ine walls.  The  ovum  forms  a  tampon,  which  fills  the  cervix  and  re- 
strains the  hgemorrhage. 

No  active  treatment  is,  therefore,  demanded.  A  carbolized  vaginal 
douche  may  be  used  twice  a  day  as  a  measure  of  cleanliness.  All 
attempts  to  disengage  the  ovum  with  the  finger  should  be  avoided,  as 
endangering  its  integrity.  The  vaginal  tampon  is  unnecessary.  It 
should  only  be  used  as  a  safeguard,  where  patients  live  at  a  distance 
from  medical  assistance  and  can  only  be  visited  at  long  intervals.  As 
it  is  never  certain  that  the  rupture  of  the  ovum  may  not  take  place 
during  the  course  of  its  expulsion,  the  tampon  may  in  such  cases  be 
employed  in  anticipation  of  a  possible  increase  of  hemorrhage  from 
sudden  collapse  of  the  membranes.  In  multiparas  the  ovum  seldom 
remains  long  in  the  cervix.  In  primiparae,  on  the  other  hand,  the 
tardy  dilatation  of  the  os  externum  may  lead  to  a  retention  of  the 
ovum  in  the  cervix,  lasting  for  days.  As  this  condition  is  extremely 
painful,  it  is  allowable  to  dilate  the  os  externum  with  the  index-finger, 
with  Goodell's  steel  dilator,  or  even  by  incisions  through  the  ring  of 
circular  fibers  which  furnish  the  cause  of  delay. 

Small  portions  of  the  decidua  vera  sometimes  remain  attached  to 
the  uterine  walls  after  abortion.  They  commonly  do  no  harm,  but 
are  discharged  with  the  lochial  secretion.  The  amount  of  the  latter 
after  abortion  is  not  usually  large  where  the  ovum  has  been  expelled 
entire.  It  is  for  the  most  part  watery,  and  does  not  usually  last  longer 
than  a  week.  A  protracted  bloody  discharge  may,  however,  be  main- 
tained by  decidual  retention.  This  is  most  apt  to  result  from  meddle- 
some interference  with  the  intact  ovum,  or  in  criminal  abortion  when 
the  expulsion  of  the  ovum  has  not  been  preceded  by  gradual  changes 
in  the  decidual  uterine  attachments.  The  decidua  can  be  safely  and 
easily  removed  by  means  of  the  dull-wire  currette.  Peliminary  dilata- 
tion of  the  cervix  is  rarely  called  for.  As  an  after  precaution  against 
infection,  cotton  soaked  in  compound  tincture  of  iodine  should  be 
passed  into  the  uterine  cavity  by  means  of  the  ordinary  applicator. 

2.  When  the  sac  ruptures  and  the  liquor  amnii  escapes,  the  re- 
moval of  the  pressure  exerted  upon  the  uterine  wall  by  the  intact 
ovum  is  followed  by  profuse  haemorrhage  from  the  utero-placental 
vessels. 

The  diagnosis  of  rupture  may  be  made  either  from  finding  the 
embryo  in  the  clots,  or,  in  the  case  of  a  dilated  cervical  canal,  by  the 
direct  examination  of  the  uterine   cavity.     Although   after  rupture 


THE   PREMATURE  EXPULSION  OF  THE   OVUM.  321 

portions  of  the  ovum  may  still  be  felt,  we  miss  the  smooth  surface 
of  the  fluctuating  amniotic  sac.  When  the  embryo  can  not  be  found, 
and  the  cervix  is  closed,  profuse  haemorrhage  alone  would  render  the 
occurrence  of  rupture  extremely  probable. 

The  principles  of  treatment  in  these  cases  are  very  simple.  The 
indications  are,  to  check  the  hemorrhage  and  to  empty  the  uterus. 
As  to  the  best  methods  of  attaining  these  results,  opinions  widely 
differ. 

When  cases  are  treated  with  rest  in  bed,  the  internal  administration 
of  ergot,  and  cold  cloths  applied  to  the  abdomen  and  vulva,  the  loss  of 
blood  is  usually  considerable,  but  the  most  of  them  terminate  favor- 
ably. In  some,  however,  the  hasmorrhage  may  prove  so  severe  as  even 
to  threaten  life.  Now,  it  is  in  every  way  desirable,  for  the  future  wel- 
fare of  the  patient,  to  restrain  the  haemorrhage  within  the  narrowest 
limits.  The  most  effectual  means  of  arresting  the  hemorrhage  is  to 
clean  out  the  uterus.  If,  therefore,  the  physician  at  the  time  of  his 
visit  finds  the  cervix  sufficiently  dilated  to  allow  him  to  introduce  his 
finger  into  the  uterus,  he  should  not  hesitate  at  once  to  remove  the 
retained  portions  of  ovum.  If  the  vagina  is  thoroughly  disinfected 
and  the  hands  are  surgically  clean,  the  operation  is  absolutely  devoid  of 
danger.  It  does  not  require  any  considerable  amount  of  technical  skill, 
while  the  immediate  results  are  in  the  highest  degree  satisfactory. 
The  patient  should  be  placed  crosswise  in  bed,  with  the  hips  drawn 
well  over  the  edge.  The  legs  should  be  flexed  and  the  thighs  held, 
where  assistants  can  be  obtained,  at  right  angles  to  the  body,  to  secure 
the  greatest  degree  of  relaxation  to  the  perineum  and  abdominal  walls. 
The  right  index-finger  should  then  be  passed  into  the  vagina  and 
through  the  cervical  canal,  while  the  left  hand,  placed  upon  the  abdo- 
men, gradually  presses  the  uterus  down  into  the  pelvic  cavity  so  as  to 
bring  it  within  reach  of  the  examining  finger.*  This  portion  of  the 
act  should  be  performed  slowly,  while  every  effort  is  made  to  divert  the 
attention  of  the  patient.  Hasty  manipulations  invariably  excite  in  the 
most  willing  of  patients  the  full  resistance  of  the  abdominal  walls. 
When  the  point  of  the  finger  reaches  the  os  internum,  it  is  sometimes 
necessary  to  pause  for  a  minute  or  two  to  await  a  sufficient  degree  of 
dilatation  to  allow  the  finger  to  pass  beyond  the  insertion  of  the  nail. 
When  the  right  finger  is  used,  it  should  be  made  to  pass  upward  with 
its  dorsal  surface  along  the  left  side  of  the  uterus  to  the  opening  of  the 
Fallopian  tube,  thence  across  the  fundus  to  the  right  side.  As  the  tip 
of  the  finger  passes  down  upon  the  right  side,  it  presses  the  detached 

*  Professor  A.  R.  Simpson  (Transactions  of  tlie  Edinburgh  Obstetrical  Society, 
vol.  iv,  p.  237)  recommends  drawing  down  the  uterus  by  means  of  volsellum- 
forceps  attached  to  the  anterior  lip  of  the  cervix.  I  have  once  seen  extreme  h.-emor. 
rhage  follow  this  manoeuvre  (seventh  month  of  pregnancy),  and  now  feel  some 
hesitation  about  its  employment,  at  least  in  the  later  months. 
21 


322  THE  PATHOLOGY  OF  PREGNANCY. 

ovum  before  it  toward  the  os  internum.  By  the  time  the  finger  has 
thus  made  the  circuit  of  the  uterus,  the  ovum  is  pressed  into  the  cervical 
canal,  and  thence  passes  easily  into  the  vagina.  With  the  left  finger, 
the  movement  is  exactly  the  reverse.  The  finger  passes  first,  with  its 
dorsal  surface  directed  to  the  right  side,  from  the  right  Fallopian  tube 
across  the  fundus,  and  downward  along  the  left  side  of  the  ut«rus. 
The  only  resistance  the  finger  meets  is  at  the  placental  insertion,  where 
a  certain  amount  of  manipulation  is  required  to  complete  the  detach- 
ment.* 

Where  the  uterus  can  not  be  pressed  down  within  reach  of  the 
index-finger  by  force  exerted  above  the  symphysis  pubis,  it  is  permis- 
sible to  introduce  the  hand  into  the  vagina ;  but,  in  such  a  case,  the 
fingers  are  apt  to  become  cramped,  and  freedom  of  manipulation  is 
impaired.  A  better  means  of  overcoming  the  difficulty  consists  in 
the  administration  of  an  anaesthetic  In  cases  of  extreme  anaemia 
chloroform  should  be  discarded  as  too  dangerous.  Ether,  hoAvever, 
has  often  seemed  to  me,  on  the  contrary,  to  possess  a  stimulating  action, 
and  its  use  to  be  followed  by  increase  in  the  volume  and  force  of  the 
pulse.  The  relaxation  produced  by  the  anaesthetic  makes  it  easy  to 
depress  the  uterus  down  to  the  pelvic  fioor,  whore  it  can  be  reached 
with  comparative  ease.  After  the  removal  of  the  ovum,  the  cavity  of 
the  uterus  should  be  washed  out  with  a  stream  of  tepid  carbolized 
water,  in  order  to  bring  away  any  small  detached  portions  of  the  ovum 
and  decidua.  In  the  manual  extraction  of  the  ovum,  deliberation  and 
perseverance  are  the  main  elements  of  success. 

If,  when  the  patient  is  first  seen  by  the  physician,  the  cervix  is  not 
sufficiently  dilated  to  allow  the  finger  to  pass  without  force,  the  vagi- 
nal tampon  should  be  employed.  The  tampon  restrains  the  haemor- 
rhage, stimulates  the  uterus  to  conti-action,  and  allows  time  for  the 
employment  of  measures  to  rally  a  patient  exhausted  by  profuse  losses 
of  blood.  The  material  of  which  it  is  made  is  a  matter  of  indifference, 
provided  only  it  fills  the  vagina  to  its  utmost  capacity.  In  cases  of 
urgent  need,  a  soft  towel,  handkerchiefs,  strips  of  cotton  cloth,  damp- 
ened cotton- wool,  and  the  like,  may  be  seized  upon  to  meet  a  temporary 
emergency.  The  time-honored  sponge,  on  account  of  its  porosity,  is 
least  deserving  of  favor.  When,  however,  the  physician  proposes  to 
leave  his  patient  for  a  number  of  hours,  the  mere  hasty  filling  of  the 
vagina  through  the  vulva  will  not  suffice.  On  the  contrary,  the  high- 
est degree  of  safety  can  only  be  secured  by  the  closest  observance  of 
the  rules  of  art. 

The  first  essential  of  a  good  tampon  is  that  it  be  carefully  packed 
around  the  cervix  uteri,  and  fill  out  the  more  dilatable  upper  portion 
of  the  vagina.     This  can  be  accomplished  only  by  the  aid  of  a  specu- 
lum.    The  method  I  usually  employ  is  one  the  credit  of  which,  so  far 
*  Vide  HiJTER,  Compendium  der  geburtshulflichen  Operationen,  p.  22. 


THE   PREMATURE  EXPULSION   OF  THE   OVUM.  323 

as  the  general  features  arc  concerned,  I  believe,  belongs  to  Dr.  Marion 
Sims.  It  consists  in  soaking  absorbent  cotton  in  carbolized  water, 
(two  per  cent)  and,  after  pressing  out  any  excess  of  tiuid,  in  forming 
from  the  cotton  a  number  of  flattened  disks  of  about  the  size  of  the 
trade-dollar.  After  the  vagina  has  been  thoroughly  washed  with  a 
carbolized  or  boric-acid  solution  the  patient  is  placed  in  the  latero- 
prone  position,  and  the  perina^uni  retracted  by  a  Sims  speculum. 
The  dampened  cotton  disks  are  introduced  by  dressing-forceps,  and, 
under  the  guidance  of  the  eye,  are  packed  first  around  the  vaginal  por- 
tion, then  over  the  os,  and  thence  the  vagina  is  filled  in  from  above 
downward  until  the  narrow  portion  above  the  vestibule  is  reached.  No 
other  plan  of  tamponing  with  which  I  am  acquainted  can  compare  in 
solidity  and  effectiveness  with  this.  Its  removal  is  accomplished  by 
the  detachment  with  two  fingers  of  a  portion  at  a  time.  This  part  of 
the  procedure  is  moderately  painful.  Many  methods  have  been  sug- 
gested to  overcome  in  the  removal  the  necessity  of  introducing  the 
finger  into  the  vagina.  A  very  ingenious  one  consists  in  attaching  the 
cotton  to  a  piece  of  twine  so  as  to  form  a  kite-tail,  which  can  be  with- 
drawn by  simply  making  tractions  upon  the  extremity  of  the  string 
left  hanging  outside  the  vulva.  Professor  I.  E.  Taylor  uses  a  roller- 
bandage.  It  is  efficient,  and,  like  the  kite-tail  described,  can  be  easily 
removed.  Dr.  F.  P.  Foster  *  advises  the  use  of  the  lamp-wicking  as  a 
nuiterial  for  the  tampon. 

No  tampon  should  be  allowed  to  remain  in  the  vagina  much  over 
twelve  hours,  and  after  its  withdrawal,  before  proceeding  to  the  exami- 
nation of  the  uterus,  the  vagina  should  be  cleansed  by  an  injection  of 
tepid  carbolized  water  (  3  ij  ad  Oj).  Often  the  ovum  is  then  found 
in  the  upper  portion  of  the  vagina  or  filling  up  the  cervix.  If  this  is 
not  the  case,  and  the  cervix  is  not  dilated,  so  that  manual  extraction 
may  easily  be  performed,  another  tampon  should  be  introduced. 

It  is  customary  from  the  outset  to  sustain  the  action  of  the  tampon 
by  the  administration  of  ergot,  either  in  the  form  of  the  fluid  extract 
(thirty  drops  every  three  to  four  hours),  or  of  a  solution  of  ergotin, 
given  hypodermically  (ergotin,  gr.  xij,  glycerin*,  3  j,  ten  minims 
twice  in  the  twenty-four  hours.  In  women  with  abundant  adipose 
tissue  the  injection  should  be  made  into  the  subcutaneous  tissues  of 
the  lower  abdomen.  In  others,  the  outer  surface  of  the  thigh  should 
be  selected). 

If  the  patient  is  collapsed  from  loss  of  blood  after  tamponing,  opi- 
ates, tea,  and  alcoholic  stimulants  should  be  administered,  the  latter 
in  small  but  frequently  repeated  quantities,  until  the  cerebral  anaemia 
is  relieved  and  the  capillary  circulation  restored. 

If,  after  the  removal,  the  cervix  is  found  not  to  be  dilated,  a  third 
tampon  may  be  introduced,  and  left  in  situ  for  another  period  of 

*  Foster,  N.  Y.  Med.  Jour.,  June,  1880. 


324  THE  PATHOLOGY  OF  PREGNANCY. 

twelve  hours.  The  employment  of  the  tampon  is  not,  however,  to  be 
recommended  for  a  period  much  exceeding  twenty-four  hours.  Its 
continued  iise  is  apt  to  irritate  the  vagina.  In  spite  of  carbolic  acid, 
it  acquires  an  offensive  odor.  It  generates  septic  matters,  which,  in  the 
long  run,  creep  upward  through  the  cervix  into  the  uterine  cavity, 
and  produce  decomposition  of  the  ovum.  I  prefer,  therefore,  in  cases 
of  undilated  cervix,  after  twenty-four  hours  of  vaginal  tamponing,  to 
resort  to  tupelo-tents.  The  tupelo-teut  is  most  easily  introduced 
when  the  patient  is  placed  upon  her  left  side,  with  the  perina?um 
drawn  back  by  Sims's  speculum,  and  the  anterior  lip  of  the  cervix 
drawn  down  and  steadied  by  a  tenaculum  (Sims's  method).  It  may, 
however,  in  the  absence  of  an  assistant,  be  introduced,  with  the 
patient  on  her  back,  by  the  aid  of  a  pair  of  strong  dressing-forceps. 
It  should  be  long  enough  to  pass  well  up  through  the  os  internum. 
Before  use  the  tent  should  be  immersed  for  a  moment  in  carbolized 
water,  and  then  dipped  in  iodoform.  Witliin  six  to  twelve  hours 
the  tent  should  be  removed,  and,  after  a  preliminary  vaginal  douche, 
manual  extraction  be  proceeded  with  in  accordance  with  the  rules 
already  given. 

In  manual  delivery  it  is  desirable  to  remove  the  decidua  as  well  as 
the  ovum.  When  the  cervix  is  patent  this  is  easy,  as  the  decidua  is 
then  detached  from  the  uterine  walls.  When  the  cervix  is  unchanged 
the  detachment  is  usually  incomplete.  In  such  cases  it  is  advisable  to 
resort  to  the  curette,  should  the  symptoms  make  action  necessary. 

Inside  the  uterine  cavity  ovum-forceps  should  be  used  with  caution. 
I  do  not  deny  its  serviceability  or  convenience  on  occasions.  Its  use, 
however,  does  not  furnish  the  certainty  that  the  uterine  cavity  has 
been  completely  emptied,  which  is  obtained  by  the  exploring  finger. 
When,  however,  the  retained  portions  of  the  ovum  have  for  the  most 
part  left  the  uterine  cavity,  and  occupy  the  cervical  canal,  the  delivery 
may  at  times  be  advantageously  hastened  by  placing  the  patient  upon 
her  side,  and,  with  the  cervix  well  brought  into  view  by  a  Sims  spec- 
ulum, applying  the  ovum-forceps,  under  the  guidance  of  the  eye,  within 
the  cervix  to  the  sides  of  the  placenta  (Skene).  But  great  care  requires 
to  be  exercised  not  to  break  away  the  fragile  structures  and  leave 
material  portions  behind. 

Under  like  circumstances,  Hoening*  recommended  a  modification 
of  Crede's  method  for  expression  of  the  placenta.  With  the  patient 
lying  upon  the  back,  the  operator,  according  to  Hoening,  should  seek 
to  compress  the  body  of  the  uterus  between  the  left  hand,  laid  above 
the  symphysis  pubis,  and  two  fingers  of  the  right  hand  introduced  into 
the  vagina.  The  measure  is  only  practicable  when  the  ovum  has,  to  a 
great  extent,  passed  from  the  uterine  cavity.  It  is  more  likely  to  be 
followed  by  the  retention  of  the  decidua.  As  it  is  somewhat  painful, 
*  Hoening,  Scanzoni's  Beitrage,  Bd.  vii,  p.  213. 


THE   PREMATURE  EXPULSION   OF  THE  OVUM.  325 

and  requires  for  success  lax  abdominal  parietes,  it  possesses  a  limited 
range  of  applicability. 

Treatment  of  Neglected  Abortion.— Where,  following  abortion,  the 
uterus  has  once  been  completely  evacuated,  haemorrhage  ceases.  A 
slight  lochial  discharge  persists  for  a  few  days  during  the  period  in 
which  the  uterine  portion  of  the  decidua  vera  completes  its  period  of 
repair.  If,  therefore,  a  patient  comes  to  us  two  or  three  weeks  after 
the  supposed  conclusion  of  an  abortion,  with  the  story  of  recurrent 
haemorrhages  taking  place,  as  a  rule,  wdienever  she  leaves  her  bed  and 
assumes  the  upright  position,  it  may  be  assumed,  with  an  approach  to 
certainty,  that  portions  of  the  ovum  still  remain  within  the  uterus. 
Oftentimes  a  fetid  discharge  points  to  the  fact  that  decomposition  has 
been  set  up.  The  absorption  of  septic  materials  may,  furthermore, 
become  the  source  of  chills,  of  fever,  and  of  great  uterine  tenderness. 
In  most  cases,  with  rest  in  bed,  the  contents  are  discharged  by  sup- 
puration, and  recovery  ultimately  takes  i)lace,  but  only  after  a  slow, 
protracted  convalescence,  during  which  pelvic  cellulitis  and  pelvic 
peritonitis  occur  as  not  uncommon  complications.  Haemorrhages, 
peritonitis,  and  sei^ticfemia  may,  however,  bring  the  case  to  a  fatal 
issue.  The  removal  of  the  retained  placenta  and  membranes  is  there- 
fore indicated,  not  only  as  a  measure  calculated  to  promote  recovery, 
but  to  avert  possible  danger  to  life. 

AVith  regard  to  the  operation  for  removal,  the  rules  already  given 
are  applicable.  The  following  peculiarities  should,  however,  be  borne 
in  mind.  In  case  the  retained  portions  are  undecomposed,  the  cervix 
is  usually  found  closed,  and  requires  preliminary  dilatation  with  the 
tent.  When  decomposition  has  once  set  in,  the  os  internum  will,  as  a 
rule,  allow  the  finger  to  pass  into  the  uterus.*  When  a  decomposed 
ovum  is  removed  by  the  finger,  a  chill  and  a  septic  fever — which  rapidly 
disappear,  however — are  apt  to  follow  in  the  course  of  a  few  hours. 
This  chill  and  fever  result  from  the  slight  traumatic  injuries  inflicted 
by  the  finger  upon  the  uterine  walls,  wdiereby  the  capillaries  and 
lymphatics  become  opened  up  to  the  action  of  the  septic  poisons. 
The  fever  ends  in  a  short  tinie,  because  the  reservoir  of  supply  is  re- 
moved with  the  debris  of  the  ovum.  If  the  uterine  cavity,  after  the 
operation,  is  carefully  washed  out  with  carbolized  water,  the  septic 
fever  is  often  averted.  After  the  irrigation  a  strip  of  iodoform  gauze 
pushed  upward  to  the  fundus  with  ovum-forceps  acts  beneficially  both 
as  a  means  of  disinfection  and  as  a  safeguard  against  luemorrhage. 
The  packing  can  be  left  in  situ  for  twenty-four  hours.  The  improve- 
ment following  the  complete  emptying  of  the  uterus  in  these  cases  is 
so  decided,  that  of  late  years  I  have  not  allowed  myself  to  be  deterred 
from  proceeding  actively,  even  when  perimetritis  and  parametritis, 
in  not  too  acute  a  form,  already  existed.  In  practice,  multitudes  of 
*  HtTER,  Compendium  cler  geburtshiilflichcn  Operationcn,  Leipsic,  1874.  p.  32. 


326  THE  PATHOLOGY  OF  PREGNANCY. 

examples  show  that  the  products  of  inflammations  situated  in  the 
pelvis  do  not  become  absorbed  so  long  as  putrid  materials  are  generated 
in  the  uterine  cavity. 

The  removal  of  a  fibi'inous  polypus,  owing  to  its  smoothness  and 
the  small  size  of  the  pedicle,  is  often  a  Sisyphus's  task.  The  separation 
can  only  be  successfully  accomplished  when  the  palmar  surface  of  the 
index-finger  presses  from  above  upon  the  point  of  attachment.  This 
necessitates  a  choice  of  hands.  Thus,  when  the  polypus  is  situated 
to  the  left,  the  right  index-finger  sliould  be  employed,  and  the  left 
index-finger  when  the  polypus  is  situated  to  the  right.  After  the 
detachment  is  complete,  it  is  necessary  to  press  the  polypoid  body 
firmly  against  the  uterine  walls,  and  proceed  with  its  withdrawal 
slowly.  If,  as  is  sometimes  the  case,  the  polypus  slips  from  under  the 
finger,  the  latter  should  be  again  passed  to  the  fundus  of  the  uterus, 
and  the  attempt  repeated.  Snuill  portions,  not  larger  than  a  pea,  can 
be  washed  out  by  the  uterine  douche.  When  the  polypus  is  situated 
near  the  os  internum,  tlie  latter  will  be  found  patulous,  but  when  it  is 
well  up  within  the  body  of  the  uterus,  dilatation  is  a  frequent  prerequi- 
site to  removal. 

For  the  removal  of  presumably  small  jiortions  of  retained  ovum, 
especially  in  cases  where,  owing  to  inflammatory  conditions,  I  have 
hesitated  to  make  the  circuit  of  the  uterine  cavity  with  my  finger, 
I  have  succeeded  admirably  by  employing  a  toleral)ly  firm  Thomas's 
wire  curette.* 

The  Treatment  of  Immature  Deliveries. — Fourth  to  seventh  month. 
— Distinctive  of  immatui-e  deliveries  are :  painful  periodic  contrac- 
tions, recognizable  by  the  liand  applied  above  the  symphysis  pubis, 
rupture  of  the  membranes  and  discharge  of  the  foetus,  the  complete 
formation  of  the  placenta  and  umbilical  cord  ;  while  in  abortion  the 
uterine  contractions  are  obscure,  the  placenta  is  rudimentary,  and  the 
ovum  is  frequently  expelled  entire.  In  the  treatment  of  immature 
delivery  the  tampon  may  usually  be  discarded.  After  rupture  of  the 
membranes  and  expulsion  of  the  foetus,  the  haemorrhage  should  be 
controlled  by  grasping  the  fundus  of  the  uterus  in  the  hand  through 
the  abdomen,  and  compressing  the  uterine  walls  firmly  together. 

The  passage  of  the  fcetus  opens  the  uterus  so  as  to  allow,  in  the 
fourth  and  fifth  months,  the  introduction  of  two  fingers ;  in  the  sixth 
and  seventh  months,  that  of  the  half-hand.  In  case  compression  of 
the  uterus  does  not  arrest  the  hemorrhage  and  expel  the  placenta,  the 
cord  should  be  carefully  followed  to  its  insertion,  to  determine  the 

*  Skene,  Med.  Record.  1875.  p.  59 ;  Munde,  Centralbl.  f.  Gyiiaek.,  1878,  No.  vi, 
p.  1.  The  patient  should  be  jilaced  in  Sims's  position,  the  perina^um  should  be 
drawn  back  with  Sims's  speculum,  the  cervi.\  hooked  down  and  steadied  with  a 
tenaculum,  while  the  curette  is  made  to  pass  over  all  portions  of  the  uterine  surface. 
Attached  bits  of  placenta  ai'e  recognized  by  the  resistance  they  offer. 


EXTRA-UTERIXE   PREGNANX'Y.  327 

side  upon  which  the  implantation  exists.  If  the  placenta  is  implanted 
upon  the  right  side,  two  or  four  fingers  of  the  right  hand,  according 
to  the  degree  of  cervical  dilatation,  should  be  passed  up  along  the  left 
side  of  the  uterus,  across  the  fundus  to  the  placental  site.  The  de- 
tachment should  be  effected  with  the  tips  of  the  fingers,  and  the  pla- 
centa pressed  downward  as  the  fingers  descend  along  the  right  side  of 
the  uterus.  The  left  hand  should  be  employed  in  the  reverse  direc- 
tion, when  the  placenta  is  situated  to  the  right. 


CHAPTER   XVII. 

EXTRA-UTERINE  PREGNANCY. 

Definition. — Tubal  pregnancy. — Pregnancy  in  rudimentary  cornu. — Interstitial 
pregnancy. — Tubo-abdoniinal  and  tubo-ovarian  pregnancy. — Ovarian  preg- 
nancy.— Abdominal  pregnancy.  —  Symptoms.  —  Terminations.  —  Diagnosis. — 
Treatment  in  cases  of  early  gestation.— Cases  of  advanced  gestation  (foetus 
living). — Cases  of  gestation  prolonged  after  the  death  of  the  foetus. 

After  coitus,  the  spermatozoa  may  make  their  way  through  the 
Fallopian  tubes  to  the  pelvic  cavity.  It  is  possible,  therefore,  for  the 
ovum  to  become  fecundated  in  any  portion  of  the  route  from  the  ovary 
to  the  uterus.  In  exceptional  cases,  the  ovum  may,  after  fecundation, 
be  arrested  in  its  travels,  and  undergo  development  at  some  point  out- 
side the  uterus.  To  these  cases  the  term  extra-uterine  pregnancy  has 
been  applied. 

In  the  past  it  has  been  assumed  that  the  ovum  may  develop  within 
the  tube,  in  the  ovary,  or  in  the  abdominal  cavity — hence  the  terms 
tn'hal.,  ovarian,  and  abdominal  pregnancii;  but  modern  research  has 
thrown  doubt  ujDon  the  existence  of  the  two  latter  varieties,  as  a  jsri- 
mary  condition.     In  any  event  they  are  extremely  rare. 

In  Mr.  Tait's*  belief,  all  cases  of  extra-uterine  pregnancy  are  nb  initio  of 
tubal  origin.  When  the  ovum  develops  in  the  free  part  of  the  tube,  rupture,  he 
holds,  occurs  at  or  before  the  fourteenth  week.  If  rujjture  occurs  at  once  into 
the  abdominal  cavity,  death  ensues  from  haemorrhage,  or  later  from  .suppuration 
of  the  sac  and  peritonitis ;  if  rupture  takes  ])lace  in  the  lower  portion  of  the 
tube  between  the  folds  of  the  broad  ligament,  the  ovum  may  develop  to  full 
term ;  may  die  and  be  absorbed  as  an  extraperitoneal  haematocele ;  may  supjju- 
rate  and  be  discharged  at  or  near  the  navel,  or  through  the  bladder,  the 
vagina,  or  intestinal  tract ;  may  remain  quiescent  as  a  litho]);edion ;  or  may  be- 
come an  abdominal  pregnancy  by  secondary  rupture.  In  the  tubo-uterine  or 
interstitial  form  death  occurs  from  intraperitoneal  rupture  before  the  fifth 
month.  Mr.  Tait  denies  the  possibility  of  a  primary  abdominal  pregnancy. 
The  ovarian  form  he  regards  as  possible  but  not  proved. 

*Tait,  Lectures  on  Ectopic  Pregnancy  and  Pelvif  Ila-matocele. 


328  THE  PATHOLOGY  OF  PREGNANCY. 

Tubal  Pregnancy. — The  ovum  may  find  lodgment  in  any  part  of 
the  tube.  The  cause  of  this  anomaly  is  most  frequently  to  be  found 
in  the  various  forms  of  chronic  salpingitis.  Owing  to  the  associated 
loss  of  epithelium,  the  dilatation  and  other  changes  in  the  tube  walls, 
the  two  active  forces  which  propel  the  ovum  through  the  tube — viz., 
ciliated  movements  and  peristalsis — are  weakened  or  destroyed,  while 
free  ingress  is  afforded  to  the  spermatozoa.  Or,  again,  the  passage  of 
the  ovum  may  be  interfered  with  by  the  secondary  results  of  catarrhal 
inflammations — such  as  the  production  of  mucous  polypi,  of  adhesions, 
or  of  sac-like  dilatations.  Formerly  great  stress  was  laid  upon  the 
etiological  importance  of  flexions  and  constrictions  resulting  from  old 
peritoneal  adhesions  and  inflammatory  bands.  Curiously  enough,  in 
recent  laparotomies  for  tubal  rupture  this  cause  has  not  played  an  im- 
portant part.  It  is  not  quite  clear  whether  the  peritonitis  formerly 
observed  so  frequently  at  autopsies  was  not  in  most  instances  second- 
ary. It  is,  moreover,  possible  that  as  a  class,  in  cases  where  ante- 
cedent peritonitis  has  existed  as  a  cause,  the  hemorrhages  result- 
ing from  rupture,  owing  to  the  agglutination  of  intestines  and  pelvic 
organs,  are  circumscribed,  and  do  not  call  for  surgical  measures  of 
relief. 

Because  of  its  connection  with  inflammatory  processes,  the  occur- 
rence of  tubal  pregnancy  is  often  preceded  by  a  long  period  of  sterility. 
When  the  obliteration  is  only  partial,  the  spermatozoa,  owing  to  their 
small  size,  are  not  prevented  from  reaching  the  arrested  ovum  ;  when 
complete,  on  the  contrary,  they  can  only  gain  access  to  the  ovum  by 
first  passing  through  the  patulous  tube,  and  then  migrating  across  the 
rear  of  the  uterus  to  the  ovary  or  the  open  abdominal  end  of  the  tube 
upon  the  opposite  side.  In  a  considerable  number  of  cases,  the  corpus 
luteum  has  been  found  upon  the  side  opposite  to  the  tube  containing 
the  fecundated  ovum.  With  the  present  prevailing  views,*  this  phe- 
nomenon is  only  to  be  accounted  for  by  the  hypothesis  of  the  migra- 
tion of  the  ovum  across  the  peritoneal  surface  of  the  pelvis  or  through 
the  uterus  from  one  tube  to  the  other. 

Kecent  observations  have  shown  that  there  is  a  tendency  for  tubal 
pregnancy  to  recur.  Thus  Herrmann  has  reported  a  case  where,  in 
performing  laparotomy  for  tubal  rupture,  he  found  the  remains  of  an 
ovum  in  the  other  tube.  Tait  f  has  reported  one  and  Veit  J  three 
cases  where,  within  a  year  or  two  after  a  first  operation  for  tubal  rupt- 

*  Mayrhofer,  Ueber  die  gelben  Korper,  und  die  Ueberwanderung  des  Eies,  de- 
nies the  whole  doctrine  of  a  distinct  corpus  hiteum  of  pregnancy,  and  claims  that 
corpora  lutea  are  found  at  stated  intervals,  perhaps  monthly,  throughout  the  entire 
period  of  pregnancy.  Leopold,  Die  Ueberwanderung  der  Eier,  Arch.  f.  Gynaek., 
Bd.,  xvi,  p.  24,  however,  found  that  after  tying  the  right  tube  and  removing  the 
entire  left  ovary  in  a  couple  of  rabbits  pregnancy  still  took  place. 

+  Tait,  British  Gynaecological  Journal,  August,  1888.  p.  178. 

X  Veit,  Gesellsch.  f.  Geburtshiilfe  und  Gynaek.  zu  Berlin,  May  10,  1889. 


EXTRA-UTERINE   PREGNANCY. 


329 


ure,  a  second  laparotomy  was  rendered  necessary  because  of  the  occur- 
rence of  pregnancy  into  the  tube  of  the  opposite  side. 

Tubal  i^regnancy  is  associated  with  the  formation  of  a  uterine  de- 
cidua  which  differs  in  no  wise  from  the  decidua  of  pregnancy,  except 
that  the  distinction  into  three  layers  is  less  marked. 

In  the  tube  a  decidua  likewise  forms  around  the  ovum.  It  contains 
large  epithelioid  cells,  as  in  uterine"  gestation.  It  differs,  however,  from 
the  latter  in  the  presence  of  connective-tissue  fibers  between  the  cell 
groups,  and  in  that  next  to  the  muscular  coat  there  is  a  transition 
zone  in  which  cells  and  muscular  and  connective-tissue  fibers  are  inter- 
mingled. Klein  *  has  reported  the  existence  of  decidual  tissue  be- 
tween the  villi  in  a  specimen  removed  from  a  patient  in  whom  rupt- 
ure occurred  seven  weeks  after  the  last  menstruation.  In  more  ad- 
vanced cases  there  is  no  serotina,  nor  is  there  any  maternal  portion  to 
the  placenta.    The  club-shaped  extremities  of  the  villi  simply  impinge 


Fio.  137.— Intraperitoneal  rupture  of  tube. 

on  the  muscular  walls.  Concerning  the  decidua  reflexa  opinions  are 
conflicting.  Frommel  and  Winckel  maintain  its  existence.  None 
was  discovered  by  Langhans,  Leopold,  Klein,  and  the  majority  of  later 
investigators.  In  Klein's  cases  tubal  vessels  opened  directly  into  the 
spaces  between  the  villi. 

In  the  early  months  the  development  of  the  ovum  leads  to  a 
spindle-shaped  dilatation  of  the  tube,  associated  with  hypertrophy  of 
the  muscular  walls  due  to  increase  in  the  length  and  thickness  of  the 
individual  fibers.     As  regards  the  degree  of  hypertrophy,  very  great 

*  Klein,  Zur  Anatomie  der  Scliwangeien  Tulic.  Zeitschr.  fUr  Geburtshiilfe  und 
Gynaek.,  vol.  xx,  p.  288  et  seq. 


330 


THE  PATHOLOGY  OF  PREGNANCY. 


individual  variations  have  been  observed.  Indeed,  in  the  same  sac  a 
thickening  at  one  point  may  be  accompanied  by  an  excessive  degree 
of  tenuity  due  to  eccentric  growth  of  the  ovum  at  another.  Now,  the 
ultimate  fate  of  a  tubal  pregnancy  is  in  large  measure  dependent  upon 
these  anatomical  differences.      Unquestionably,  early  rupture   is   the 


=3  i^ 


rule.  Mr.  Tait  says  :  "  Out  of  an  enormous  number  of  specimens  which 
I  have  examined,  I  have  entirely  failed  to  satisfy  myself  that  rupture  has 
been  delayed  later  than  the  twelfth  week."  It  seems  to  me,  however, 
carrying  skepticism  too  far  to  refuse  credence  to  the  positive  observa- 
tions of  others,  made  apparently  with  the  utmost  care  and  with  full 


EXTRA-UTERINE   PREGNANCY.  331 

knowledge  of  possible  sources  of  error,  which  seem  to  show  that  a  tubal 
pregnancy  may  exceptionally  reach  advanced  or  even  the  full  term  of 
pregnancy.  At  present  it  seems  fair  to  assume  that,  when  the  sac 
which  surrounds  the  ovum  is  composed  of  muscular  and  connective-tis- 
sue fibers  with  an  external  peritoneal  envelope,  and  directly  communi- 
cates with  the  Fallopian  tube,  the  sac  walls  are  of  tubal  origin.  Of 
course  it  is  not  possible  to  assert  that  no  rupture  has  taken  place  in  the 
course  of  development.  It  is  only  known  positively  that  rupture  occur- 
ring at  the  site  of  placental  attachment  gives  rise  to  hemorrhage  fatal 
to  the  fa?tus ;  and  the  same  is  true,  with  rare  exceptions,  where  rupture 
occurs  at  any  jjoint  of  the  peritoneal  surface.  That  rupture  has  first 
occurred  into  the  cavity  of  the  broad  ligament  in  all  the  cases  which 
go  on  to  the  period  of  viability  does  not  seem  so  absolutely  certain. 
The  anatomical  appearances,  in  some  instances  at  least,  indicate  that  the 
exposure  of  the  fetal  membranes  here  and  there  through  the  maternal 
sac  results  not  so  much  from  laceration  as  from  the  gradual  separation 
of  the  muscular  fibers  due  to  excessive  stretching.*  In  most  of  the 
cases  in  Avhicli  the  pregnancy  reaches  an  advanced  stage  the  develop- 
ment of  the  tube  takes  place  principally  between  the  folds  of  the  broad 
ligament.  The  support  furnished  the  tubal  sac  by  the  gradual  unfold- 
ing of  the  ligament  layers  hinders  rupture.  More  rarely  pregnancy 
may  go  to  the  period  of  viability  Avithout  encroaching  upon  the  intra- 
ligamentous space.  The  tumor  then  rises  above  the  pelvic  brim,  and 
is  furnished  with  a  species  of  pedicle  consisting  of  the  uterine  end  of 
the  tube  and  of  the  broad  ligament. 

The  first  of  the  above,  or  the  intraligamentous  form,  lies  close  to 
the  uterus,  which  it  not  infrequently  crowds  upward  and  forward. 
The  uterine  end  of  the  tube  varies  greatly  in  length.  The  fimbriated 
extremity  is  unrecognizable.  Usually  no  traces  of  the  ovary  are  found. 
In  the  so-called  pedicled  form  the  uterus  is  crowded  to  one  side  or  re- 
tro verted.  The  uterine  end  of  the  tube  is  usually  long  and  thickened. 
The  corresponding  ovary  has  generally  been  discovered.  In  both  cases 
the  relations  of  the  sac  are  often  obscured  by  adhesions  to  adjacent 
viscera.  In  the  second  half  of  pregnancy  rupture  of  the  sac  and  the 
escape  of  the  foetus  into  the  peritoneal  cavity  may  occur  without  no- 
ticeable h;i?morrhage  or  without  interruption  of  pregnancy.  As  the 
pressure  is  removed  by  the  escape  of  the  amnrotic  fluid,  the  placental 
borders  curl  inward  so  as  to  furnish  a  cup-like  space,  while  the  mem- 
branes sink  downward  and  cover  the  upper  placental  surface.  The 
fu?tus  in  these  cases  may  occupy  the  abdominal  cavity,  or  a  sac  may  be 
formed  by  the  agglutination  of  the  adjacent  viscera. 

Werth  has  reported  a  case  in  Avliich  death  of  the  embryo  occurred 
in  the  second  month,  and  was  followed  by  haemorrhage  which  i)0ured 

*  Vtde  tables  of  Wertli.  BeitWige  zur  Anatoinie  unci  zur  operativen  Behaiullung 
der  Extrauterinschwangerschaft. 


332 


THE  PATnOLOGY  OF  PREGNANCY. 


through  the  abdomiual  end  of  the  tube  into  the  pelvic  cavity  and  gave 
rise  to  intraperitoneal  hematocele.  Similar  observations  have  been 
made  by  Veit  and  Westermark.  This  form  Werth  terms  tubal  abor- 
tion, in  another  case  described  by  Wyder  the  fimbriated  extremity  of 
the  tube  was  obliterated,  and  as  a  consequence  the  hemorrhage  follow- 
ing the  separation  of  the  ovum  converted  the  ampulla  of  the  tube  into 
a  blood  cyst  the  size  of  the  fist.* 

Pregnancy  in  the  Rudimentary  Cornu  of  a  One-horned  Uterus.— 
This  anomaly  so  closely  resembles  the  tubal  form  of  pregnancy  that 
the  diagnostic  distinction  can  rarely  be  established  during  life.  In 
tubal  pregnancy  rupture  takes  place,  as  a  rule,  in  the  first  three  months, 
while  the  rupture  of  the  cornu  occurs  somewhat  later,  usually  between 


Fig.  139.— Pregnancy  in  rudimentary  cornu.    (Kussniaul,  observed  bf  Heyfelder.) 

the  third  and  sixth  months.  Cases  have,  however,  been  reported  by 
Turner,!  Werth,J  and  Salin,*  in  whicli  gestation  went  to  full  term. 
Rupture  takes  place  at  the  apex  of  the  cornu.  In  several  instances  in 
which  surgical  procedures  have  been  employed  for  this  anomaly,  the 
removal  of  the  entire  sac  has  been  rendered  easy  by  the  presence  of  a 
well-formed  pedicle. 

Interstitial  Pregnancy. — The  term  interstitial  pregnancy  is  applied 
to  cases  in  which  the  ovum  is  developed  in  the  uterine  portion  of  the 


*  Op.  cit.,  pp.  105, 106. 

X  Archiv  f.  Gynaek.,  vol.  xvi,  p.  281. 


f  Edinburgh  Med.  Join-.,  May,  1886,  p.  074. 
«  Centralblatt  f.  Gynaek.,  1881,  p.  221. 


EXTRA-UTERINE   PREGNANCY. 


333 


tube.  The  latter  measures  about  seven  lines  in  length  by  one  line  in 
diameter.  At  first  the  muscular  walls  hypertrophy  and  form  around 
the  ovum  a  sac  which  projects  from  the  upper  angle  of  the  uterus. 
As,  ordinarily,  the  growth  of  the  muscular  tissue  does  not  keep  pace 


Fig.  140.— Interstitial  pregnancy.    (Hennig.) 

with  that  of  the  ovum,  rupture  occurs  at  an  early  period.  Of  twenty- 
six  such  cases  collected  by  Hecker,  all  ruptured  before  the  sixth  month. 
Tait  says  that,  "  so  far  as  known,  interstitial  pregnancy  is  uniformly 
fatal  by  primary  intraperitoneal  rupture  before  the  fifth  month." 
Schwarz,*  however,  reports  a  case  belonging  to  this  category  in  which 
the  foetus  was  expelled  into  the  uterine  cavity. 

The  patient  was  known  to  be  pregnant.  Repeated  ha?morrhages 
indicated  a  threatened  abortion.  To  avoid  further  dangers,  the  cervix 
was  dilated  with  the  view  to  empty  the  uterus.  On  examination  with 
the  finger  the  uterine  cavity  was  found  empty,  but  there  was  a  piece  of 
membrane  at  the  uterine  opening  of  the  left  tube,  wliich  was  removed. 
The  next  day  the  finger  detected  membrane  at  tlie  same  site,  and,  be- 
yond, a  hard  body.     The  uterus  began  to  contract  energetically.     On 

*  Schwarz,  Wiener  nied.  Blatter,  1886.  In  the  abstract  furnished  by  Grandin 
in  the  American  Journal  of  Obstetrics  (January,  1887,  p.  101).  the  date  of  pregnancy 
IS  not  given.  Similar  cases  have  been  reported  by  Dr.  Charles  :McIiurney  (New 
York  Med.  Jour.,  March,  1878,  p.  273)  and  by  Dr.  Cornelius  Williams  (in  the  De- 
cember number  of  the  same  journal,  p.  595),  both  of  which  were  followed  by  the  re- 
covery of  the  mother. 


334 


THE  PATHOLOGY  OP  PREGNANCY. 


the  fifth  clay  a  foetus  was  passed  by  the  vagina,  the  pains  ceased,  the 
tumor  largely  disappeared,  and  the  f)atient  made  a  good  convalescence. 

Martin  removed  a  male  foetus  33  centimetres  long  (six  months) 
from  the  left  uterine  cornu.  The  patient  recovered.  Duvelius,  who 
examined  the  specimen,  concluded  that  the  ovum  had  2)artially  grown 
into  the  tube  and  between  the  folds  of  the  broad  ligament.  He 
thought  that  rupture  did  not  occur  owing  to  the  number  of  the  muscu- 
lar elements  in  the  sac  wall.* 

A  possible  form  of  interstitial  pregnancy  is  furnished  by  the 
occasional  existence  of  a  canal,  open  at  its  two  extremities,  and  appar- 
ently a  continuation  or  a  bifurcation  of  the  Fallopian  tube.  A  case 
reported  by  Dr.  Gilbert,  in  the  Boston  Medical  and  Surgical  Jour- 
nal (March  3,  1877),  where  the  head  of  the  child  could  be  felt  just 
above  the  os  internum,  covered  by  a  thin  mucous  membrane,  and  in 
which  delivery  was  successfully  accomplished  by  an  incision  through 


Fig.  141.— Bifurcation  of  tubal  canal.    (Hennig.) 

the  partition,  probably  belonged  to  this  variety.  A  similar  case,  in  the 
practice  of  Dr.  H.  Lenox  Hodge,  is  reported  by  Parry  {op.  cit.,  p.  266). 

In  the  post-mortem  examinations  the  distinction  between  an  inter- 
stitial pregnancy  and  one  in  a  rudimentary  cornu  is  not  easy  to  make 
out.  The  chief  points  of  difference  consist  in  the  fact  that  in  inter- 
stitial pregnancy  the  sac  communicates  by  an  orifice  with  the  uterine 
cavity,  or  is  separated  from  the  uterus  by  a  partition,  while  in  preg- 
nancy in  a  rudimentary  cornu  the  two  halves  of  the  uterus  are  united 
by  a  muscular  band,  which  is  situated  not  at  the  upper  angle  but  near 
the  OS  internum. 

Ovarian  Pregnancy. — In  spite  of  modern  skepticism,  there  is  little 
question  as  to  the  occasional  occurrence  of  ovarian  pregnancy.  The 
specimen  discovered  by  Patenkof  in  the  Pathologico- Anatomical 
Museum  of  St.  Petersburg  seems  to  answer  all  the  requirements  of  a 

*  Martin,  Ztschr.  f.  Geb  und  Gynaek.,  vol.  xi,  p.  416. 

f  Patenko,  Casuistische  Mitteilungen,  Arch.  f.  Gynaek.,  vol.  xiv.  p.  156. 


EXTRA-UTERINE   PREGNANCY.  335 

demonstration.  The  right  ovary  was  of  the  size  of  a  hen's  egg,  and 
contained  a  cyst  with  smooth  walls  filled  with  serum.  In  this  he  found 
a  body  of  a  yellow  color,  of  the  size  of  a  hazel-nut,  which  contained 
cylindrical  and  flat  bones.  The  most  careful  microscopical  examina- 
tion established  the  fact  that  the  bones  were  those  of  a  foetus,  and  not 
merely  the  chance  products  of  a  dermoid  cyst.  The  presence  of 
corpora  lutea  and  follicles  in  the  walls  of  the  envelope  proved  that  the 
body  was  an  ovary.  The  tube  on  the  corresponding  side  was  nowhere 
adherent  to  the  sac.  The  abdominal  extremity  was  closed,  and  there 
were  no  traces  of  fimbriae.* 

Paltauf  f  relates  a  case  of  extra-uterine  pregnancy  in  which  there 
was  a  sacculated  condition  of  both  tubes  which  communicated  with  a 
cyst  of  ovarian  origin.  The  ovaries  were  closely  united.  By  means  of 
the  ovarian  cyst  a  complete  communication  was  established  between 
the  two  tubes.  In  the  large  central  ovarian  cyst  a  clot  was  found 
which  contained  an  embryo  corresponding  in  size  to  one  of  from  forty- 
five  to  forty-eight  days'  development.  The  origin  of  the  condition 
here  met  with  is  naturally  a  matter  of  speculation. 

Abdominal  Pregnancy. — In  most  cases  of  abdominal  pregnancy  a 
connective-tissue  proliferation  is  set  up  about  the  ovum,  which  sur- 
rounds it  with  a  vascular  sac.  The  latter  often  attains  a  degree  of 
thickness  which  renders  it  comparable  to  the  gravid  uterus  (Klob). 
The  walls  keep  pace,  as  a  rule,  with  the  growth  of  the  ovum,  and,  as 
they  extend  into  the  abdominal  cavity,  form  adhesions  to  the  intestines, 
the  mesentery,  and  omentum.  It  is  claimed  that  organic  muscular 
fibers  have  been  found  in  the  sac,  especially  near  the  uterine  attach- 
ment.    In  this  form  the  foetus  most  frequently  reaches  maturity. 

In  rare  cases  the  ovum  develops  free  in  the  abdominal  cavity,  with- 
out the  formation  of  pseudo-membranes,  the  foetus  being  surrounded 
solely  by  the  amnion  and  chorion. 

The  greater  number  of  so-called  abdominal  pregnancies  are  un- 
questionably of  tubal  origin.  In  reality  they  are  for  the  most  part 
extraperitoneal,  and  result  from  a  rupture  in  the  tube  walls  occurring 
between  the  folds  of  the  blood  ligament.  In  these  cases  the  conditions 
are  not  incompatible  with  continued  fetal  development,  and  gestation 
may  reach  an  advanced  stage. 

The  question  as  to  the  occurrence  of  primary  abdominal  pregnancy 
must  be  regarded  as  unsettled.     The  discovery  of  an  ovum  growing  in 

*  Mr.  Tait,  in  his  recent  work  on  Ectopic  Pregnancy,  refers  to  a  specimen  de- 
scribed by  Dr.  Walter  as  one  of  primary  ovarian  pregnancy  (sac  had  ruptured  at 
fifth  month,  and  foetus  had  escaped  into  peritoneal  cavity),  which  is  now  in  the 
Dorpat  Museum,  and  suggests  a  careful  investigation  as  to  its  real  character.  At 
Werth's  request  this  has  since  been  made  by  Runge,  with  a  complete  confirmation 
of  the  significance  given  to  it  by  Walter  in  his  original  publication.  Werth, 
loc.  cit.,  p.  64. 

f  Paltauf,  Arch.  f.  Gynaek.,  vol.  xxx,  p.  4.j(5. 


336  THE  PATHOLOGY  OF  PREGNANCY. 

the  peritoneal  cavity  with  the  tubes  and  ovaries  demonstrably  intact 
would  suffice  to  establish  the  abdominal  variety.  In  the  early  months, 
before  the  anatomical  conditions  are  obscured  by  secondary  changes, 
there  is  no  pretense  that  such  proof  has  been  obtained.  In  more  ad- 
vanced stages  a  good  many  cases  of  assumed  abdominal  pregnancy 
have  been  placed  in  evidence.  These,  so  far  as  my  investigations  per- 
mit me  to  judge,  are  divisible  into  two  classes : 

1.  Cases  where  the  tubes  are  reported  as  intact,  but  in  which  there 
exists  a  direct  communication  between  the  tube  upon  the  affected  side 
and  the  sac  cavity.  Thus  Treub,  of  Leipsic  reports  the  following 
instance : 

Patient  menstruated  last  about  the  middle  of  April,  1887  ;  perito- 
nitic  pains,  with  symptoms  of  internal  haemorrhage,  on  tlie  ll^th  of 
June.  At  the  end  of  July  the  same  symptoms  occurred,  but  were  more 
violent.  Ballottement  was  distinct  by  the  end  of  September.  Life 
was  felt  a  week  later.  There  were  no  fetal  movements  after  November 
24th.  Septic  symptoms  developed,  and  laparotomy  was  performed 
January  22,  1888,  when  the  patient  was  nearly  moribund.  Death  en- 
sued the  following  night. 

At  the  autopsy  the  annexa  on  the  right  side  were  normal.  The 
left  tube  measured  ten  centimetres  and  a  half,  which  corresponded  to 
the  length  of  the  right  tube.  It  was  pervious  throughout  its  entire  ex- 
tent. The  fimbriated  outer  end  communicated  with  the  sac.  There 
was  no  apparent  distention  of  the  abdominal  end  of  the  tube.  The 
sac  of  the  ovum  was  adherent  to  the  posterior  surface  of  the  uterus 
and  of  the  broad  ligament,  to  a  few  coils  of  intestines,  to  the  sigmoid 
flexure,  and  to  the  rectum. 

Abdominal  pregnancy  was  assumed  by  Treub  because  the  tube  had 
its  normal  length  and  its  natural  direction,  while  the  placenta  was 
attached  to  the  posterior  sac  wall,  which  contained  no  muscular  ele- 
ments, even  in  the  vicinity  of  the  tube.  It  has  been  suggested,  how- 
ever, that  this  was  a  case  where  the  fecundated  ovum  occupying  the 
infundibulum  ruptured  the  tube  walls  at  an  early  period  of  its  growth, 
and  thence  continued  its  development  between  the  folds  of  the  broad 
ligament.  It  will  be  remembered  that  there  were  unmistakable  symp- 
toms of  internal  haemorrhage  in  June  and  in  July.  The  length  of  the 
left  tube  does  not  affect  the  question,  as  Werth  *  furnishes  cases  of  un- 
mistakable intraligamentous  development  where  the  same  feature  was 
noted. 

3.  Cases  where  the  tubes  are  reported  as  intact  and  not  in  commu- 

*  Werth,  Beitrage  zur  Anatomie  und  zur  operativen  Behandlung  der  Extra- 
uterinschwangerschaft,  1887.  Vide  Table  A,  containing  sixteen  cases  of  intraliga- 
mentous tubal  pregnancy.  In  No.  9,  Scott's  case,  the  length  of  the  tube  was  given 
at  six  inches  ;  in  No.  12,  Dreesen's  ease,  at  fifteen  centimetres;  in  No.  15,  Martyn's 
case,  the  statement  is  made  that  the  tube  was  enormously  increased  in  length. 


EXTRA-UTERINE  PREGNANCY. 


337 


nication  with  the  sac.  Few  of  these  merit  criticism.  Lately,  however 
new  interest  has  been  excited  as  to  the  possibility  of  primary  abdomi- 
nal pregnancy  by  a  case  operated  upon  in  1879  by  Professor  Miiller,* 
of  Bern.  Extra-uterine  and  intra-uterine  pregnancy  existed  at  the 
same  time.  At  the  eighth  month  spontaneous  expulsion  of  the  intra- 
uterine foetus  took  place.  The  extra-uterine  ovum  Avas  removed  bv 
laparotomy.  Death  ensued  from  ha?morrluige.  The  post-mortem  in- 
vestigation was  conducted  by  Walker,  who,  in  a  carefully  prepared 
essay,  concludes  that  the  case  Avas  a  typical  one  of  abdominal  preg- 
nancy. The  tubes  and  ovaries  were  in  contact,  but  not  adherent  to 
the  sac.  The  latter  had  started  originally  from  the  bottom  of  the 
cul-de-sac  of  Douglas,  and  only  in  the  course  of  its  subsequent  develop- 
ment had  reached  the  uterine  appendages.  The  correctness  of  the 
author's  deductions  has  not,  hoAvever,  passed  unchallenged,  most  of  the 
recent  reviewers  regarding  the  history  as  indicating  a  tubal  origin. 

Schlectendahl  f  reports  the  discovery  of  an  ovum  near  the  spleen, 
containing  a  foetus  measuring  fifteen  centimetres  in  length,  in  a  woman 
who  had  died  from  internal  hsemorrhage.  The  sac  Avas  the  size  of  a 
man's  fist,  and  Avas  surrounded  by  adherent  intestines.  The  uterus  and 
tubes  appeared  normal.  '  The  value  of  this  case  as  evidence  on  behalf 
of  abdominal  pregnancy  has  been  denied,  but  the  facts  related  by 
Schlectendahl  certainly  call  for  explanation. 

Of  very  great  interest  are  the  cases  of  so-called  secondary  abdomi- 
nal pregnancies,  where  rupture  of  the  sac  and  the  fetal  membranes 
takes  place  and  the  foetus  passes  into  the  abdominal  caA^ty.  Most 
often  the  child  dies  at  or  soon  after  the  time  of  rupture,  but  cases  are 
reported  by  Walter,  Patuna,  and  Bandl,J  where  it  continued  to  de- 
velop within  the  abdomen.  The  presence  of  the  child  usually  excites 
an  active  proliferation  of  connective  tissue,  by  means  of  which  a  sec- 
ondary sac  is  formed,  though  in  Jessup's  case  the  child  was  absolutely 
free  in  the  abdominal  cavity.  If  the  child  dies,  it  may  either  become 
converted  into  a  lithopaedion,  or,  through  the  vascular  connective  tis- 
sue by  Avhich  it  is  surrol^nded,  the  soft  structures'of  the  body  may  pre- 
serve their  integrity  for  years  succeeding  the  fatal  ending. 

There  are,  in  addition  to  the  varieties  already  mentioned,  histories 
on  record  of  the  coexistence  of  extra-uterine  and  intra-uterine  preg- 
nancies, the  latter  occurring  at  the  same  menstrual  period  as  the  for- 
mer, or  subsequent  to  the  death  of  the  extra-uterine  foetus.* 

*  Vide  L.  Bruhl,  Zur  Casuistik  der  ExtrauterinschAvangersehaft,  Arch.  f. 
Gynaek.,  vol.  xxx,  p.  70,  and  Walker,  Der  Bau  der  Eihaute  bei  graviditas  abdomi- 
nalis,  ViRCHOw's  Arch.,  vol.  cvii. 

f  Schlectendahl,  Ein  Fall  von  graviditas  abdominalis,  Frauenarzt,  1887,  No.  2. 
X  Bandl,  loc.  cii.,  p.  63. 

*  Vide  Broavne,  Contribution  to  the  History  of  Combined  Intra-uterine  and 
Extra-uterine  Twin  Pregnancy,  Avith  an  Analysis  of  TAventy-four  Cases,  Trans.  Am. 
Gynaec.  Soc,  vol.  vi,  p.  444. 

22    - 


338  THE  PATHOLOGY  OF  PREGNANCY. 

Tubo-Abdominal  and  Tubo-Ovarian  Pregnancy.— When  the  ovum 
becomes  lodged  near  the  trumpet-shaped  extremity  of  the  Fallopian 
tube  it  may  grow  outward  into  the  abdominal  cavity.  Local  peritonitis 
is  then  set  up,  and  plastic  exudation  is  thrown  out,  forming  an  envelope 
around  the  ovum,  which  is  likewise  bounded  by  the  contiguous  organs. 
In  tliis  way  the  ligamenta  lata,  the  ovaries,  the  mesentery,  the  in- 
testines, the  bladder,  and  the  uterus,  may  all  contribute  to  the  invest- 
ment of  the  fetal  membranes.  In  case  of  rupture  in  the  tubal  portion 
inflammatory  products  may  form,  and  limit  the  extent  of  the  injury. 
At  first,  owing  to  its  weight,  the  distended  tube  drops  into  the  cul- 
de-sac  of  Douglas.  In  advanced  pregnancy,  the  spleen,  kidneys,  and 
liver  may  become  involved,  and  form  part  of  the  sac-walls  around  the 
ovum.     Usually  the  placenta  is  developed  in  the  pelvic  cavity.* 

When  the  investment  of  the  ovum  is  furnished  by  the  tube  and 
the  ovary,  the  term  tubo-ovarian  pregnancy  is  employed.  The  course 
in  either  case  does  not  materially  differ  from  that  of  an  abdominal 
pregnancy. 

The  Symptoms  of  Extka-uterine  Preg^tancy. 

The  earlier  symptoms  of  extra-uterine  preg^nancy  do  not  materially 
differ  from  those  of  the  intra-uterine  form.  Menstruation  usually 
ceases,  though  not  with  the  same  regularity  as  in  normal  pregnancy. 
The  recurrence  of  the  monthly  flow  for  one  or  two  periods  is  not  an 
uncommon  incident.  In  some  cases,  too,  a  nearly  continuous  sero- 
sanguinolent  discharge  of  moderate  extent  has  been  observed;^  Up  to 
a  certain  point  the  hypertrophic  changes  of  the  uterus  take  place  in 
the  usual  manner.  The  mucous  membrane  is  converted  into  a  de- 
cidua,  and  a  mucous  plug  fills  the  cervix.  In  general  terms,  the  length 
of  the  uterus  is  greater  the  closer  the  contiguity  of  the  ovum  to  the 
uterus.  In  a  few  cases  of  tubal  pregnancy  there  has  been  no  increase 
in  the  size  of  the  uterus.  The  extra-uterine  ovum  may,  in  the  course 
of  its  growth,  drag  the  uterus  upward,  or  push  it  downward,  forward, 
or  to  the  side,  according  to  the  site  of  its  development. 

Characteristic  symptoms  of  extra-uterine  pregnancy  do  not  occur 
until  the  ovum  has  reached  a  certain  degree  of  growth,  and  in  some 
cases  not  until  rupture  has  taken  place.  Often  preceding  rupture,  or, 
in  abdominal  pregnancies,  the  death  of  the  foetus,  the  patient  suffers 
from  paroxysmal  pains  in  the  sac,  and  uterine  pains  of  a  labor-like 
character.  The  latter  are  associated  with  a  sero-sanguinolent  dis- 
charge, and  are  followed  by  the  expulsion  of  portions  of  the  decidua. 

The  symptoms  of  rupture  are  the  usual  ones  of  internal  haemor- 
rhage, viz.,  yawning,  languor,  fainting,  clammy  perspiration,  rapid 
pulse,  intermittent  vomiting,  collapse,  and  acute  anaemia.     After  the 

*  Vide  Bandl,  Billroth's  Handbuch  der  Prauenkrankheiten,  5ter  Abschnitt, 
p.  47. 


EXTRA-UTERINE   PREGNANCY.  339 

death  of  the  ovum  these  symptoms  may  cease  and  not  return  again ; 
whereas,  if  the  ovum  continues  to  grow,  there  may  be  repeated  attacks 
of  haemorrhage  and  local  peritonitis. 

When  the  death  of  the  ovum  does  not  occur  within  the  first  three 
to  four  months,  the  pressure  of  the  tumor  usually  gives  rise  to  dysuria 
and  constipation. 

Terminations. — The  investigations  resulting  from  the  recent  wide- 
spread interest  in  the  diseases  of  the  uterine  appendages  have  shown 
that  tubal  pregnancy  is  by  no  means  of  rare  occurrence.  Whereas,  in 
tubal  and  interstitial  pregnancies,  it  was  formerly  believed  that  the  usual 
terminations  were  rupture  of  the  sac,  h£emorrhage,  peritonitis,  and 
death,  it  is  now  known  that  in  a  pretty  large  percentage  of  cases  the 
ovum  perishes  at  an  early  period  of  development;  and,  though  the 
sequelae  of  these  so-called  tubal  abortions  may  cause  discomfort  or  lay 
the  foundation  for  chronic  invalidism,  they  do  not  necessarily  lead  to 
a  fatal  result.  As  in  cases  of  uterine  abortion,  the  death  of  the  ovum 
is  for  the  most  part  followed  by  haemorrhage,  which  may  be  confined 
to  the  tube  (haematoma  tubae),  or  the  blood  may  escape  by  the  fimbri- 
ated extremity  into  the  peritoneal  cavity,  or,  if  circumscribed  by  adhe- 
sions, it  may  give  rise  to  the  intraperitoneal  form  of  pelvic  haematocele. 
Even  when  rupture  takes  place  the  haemorrhage  is  not  necessarily  fatal. 
Mr.  Tait  insists  on  the  relative  harmlessness  of  most  cases  of  haema- 
toma due  to  rupture  occurring  between  the  folds  of  the  broad  ligament ; 
while  the  records  of  salpingotomy  show  that,  even  with  intraperi- 
toneal rupture,  the  haemorrhage  has  often  been  found  moderate  in 
amount,  and  did  not  in  itself  furnish  the  occasion  for  surgical  inter- 
ference.* 

In  abdominal  pregnancies,  which  it  has  been  seen  are  usually  if  not 
always  secondary  to  the  tubal  form,  the  ovum  or  foetus,  as  a  rule,  excites 
a  local  peritonitis,  attended  with  pain  and  fever,  and  followed  by  the 
production  of  pseudo-membranes,  which  exercise  a  conservative  influ- 
ence by  shutting  off  the  ovum  from  the  peritoneal  cavity.  Indeed,  in 
the  exceptional  instances  where  these  inflammatory  conditions  do  not 
develop,  the  movements  of  the  foetus  within  its  own  membranes  may 
give  rise  to  such  intense  suffering  as  to  cause  the  woman  to  die  from 
exhaustion  (Schroeder). 

In  abortions  at  an  early  stage  it  often  happens  that  no  trace  of  the 
embryo  is  found,  and  the  diagnosis  has  to  be  made  from  the  presence 
of  the  chorionic  villi.  Even  when  abortion  does  not  occur  in  the  first 
few  weeks  the  child  is  apt  to  die  prematurely.  Sometimes,  however, 
gestation  may  advance  to  full  term ;  in  which  case  labor-pains  set 
in,  the  decidua  is  expelled,  and  the  child  dies  during  the  expulsive 
efforts.  In  the  majority  of  cases  the  dead  foetus  excites  a  suppurative 
inflammation  in  the  sac  by  which  it  is  inclosed,  and  the  patient  dies 
*  Vide,  as  an  instance,  the  cases  reported  by  Orthman  from  Martin's  Clinic. 


340  THE  PATHOLOGY  OF  PREGNANCY. 

either  from  general  peritonitis  or  from  profuse  suppuration.  In  cases 
where  the  peritonitis  remains  local  and  the  suppuration  is  tolerated, 
fistulous  communications  may  form  with  one  of  the  hollow  viscera  or 
the  abdominal  walls,  through  which  the  contents  of  the  sac  may  be 
eliminated.  Most  frequently  the  opening  takes  place  into  the  large 
intestine ;  quite  often  through  the  abdominal  walls ;  more  rarely  into 
the  vagina  and  bladder.  In  any  case,  the  process  of  elimination  is 
slow,  often  lasting  months,  and  even  years.  When  the  bones  and  soft 
tissues  have  all  been  discharged,  complete  recovery  may  take  place.  In 
the  larger  proportion  of  cases,  however,  if  Nature  is  not  assisted,  the 
patient  perishes  from  exhaustion  and  blood-poisoning  before  the  elimi- 
nation is  ended. 

Sometimes  the  foregoing  inflammatory  changes  do  not  occur  as  the 
result  of  the  death  of  the  foetus,  in  which  case  the  fluid  contents  of 
the  sac  are  re-absorbed,  and  the  walls  collapse  and  come  in  contact  with 
the  fetal  cadaver.  The  skin  of  the  latter,  and  at  a  later  period  the 
deep-seated  soft  tissues,  undergo  fatty  degeneration,  and  form  a  greasy 
substance  consisting  of  fat,  lime-salts,  cholesterin-crystals,  and  blood- 
pigment.  Afterward  the  fluid  portions  are  absorbed,  so  that  nothing 
remains  but  the  bones,  lime  lamellee,  and  incrustations  upon  the  walls 
of  the  sac ;  or  the  foetus  may  shrink  up  like  a  mummy,  preserving  its 
shape  and  organs  to  the  minutest  detail.  A  foetus  thus  altered  is 
termed  a  lithopaedion.  It  may  remain  imbedded  in  connective  tissue 
for  years  without  injury  to  the  mother.  The  lithopaedion  of  Leinzell 
was  removed  in  1720  from  a  woman  ninety-four  years  of  age,  who  had 
carried  it  for  forty-six  years.  The  presence  of  the  lithopaedion  does  not 
prevent  pregnancy  from  taking  place.  In  some  cases  it  may  after  years 
excite  suppuration,  a  result  which  is  fostered,  according  to  Spiegelberg, 
by  pregnancy  and  labor.  Recovery  may  follow  the  -artificial  extraction 
of  the  foreign  body,  or  death  may  result  from  inflammation  and  the 
discharge  of  pus. 

Note. — Kiichenmeister  (Ueber  Lithopadien,  Arch.  f.  Gynaek.,  vol.  xvii,  p.  153) 
distinguishes  three  conditions  to  which  the  term  lithopaedion  is  applied  : 

1.  Where,  after  absorption  of  the  fluid,  the  membranes  alone  calcify,  and  the 
foetus  undergoes  mummification. 

2.  Where,  after  absorption  or  escape  of  the  fluid,  the  membranes  calcify,  and 
calcification  of  the  foetus  occurs  at  points  where  the  membranes  adhere  to  the  fetal 
surface. 

3.  Where  the  foetus  escapes  into  the  abdominal  cavity,  and  cretaceous  matter  is 
deposited  in  the  smegma  covering  the  fetal  surface.  In  this  way  calcified  strata 
form  around  the  foetus  and  exert  compression  upon  the  contained  tissues.  Beneath 
the  chalky  layers  the  tissues  are  mummified.  A  lithopaedion  in  the  sense  of  a  com- 
plete petrifaction  does  not  exist. 

Diagnosis, — The  diagnosis  of  extra-uterine  fetation  is  based  upon 
the  existence  of  the  signs  of  pregnancy,  the  exclusion  of  an  ovum  within 
the  uterine  cavity,  and  the  presence  of  a  tumor  external  to  the  uterus. 


EXTRA-UTERINE   PREGNANCY.  341 

In  practice,  however,  there  is  a  wide-spread  difference  of  opinion  as 
to  the  practicability  of  an  early  diagnosis  ©f  tubal  pregnancy.  Dr. 
Hanks  has  recently  stated  his  belief  that  a  diagnosis  can  be  made  in 
ninety-five  per  cent  of  the  cases  we  are  called  upon  to  attend.  Mr. 
Tait,  on  the  other  hand,  thinks  "  he  may  be  excused  for  maintaining  a 
somewhat  skeptical  attitude  concerning  the  correctness  of  the  diagno- 
sis of  these  gentlemen  who  speak  of  making  a  certain  diagnosis  before 
the  period  of  rupture." 

The  problem  seems  simple  enough.  Given  pregnancy,  and  having 
ascertained  that  the  ovum  is  not  in  the  uterus,  the  diagnosis  is  effected. 
But  we  all  know  that  the  subjective  symptoms  of  pregnancy  are  decep- 
tive, and  that  the  pigmentation,  the  mammary,  and  the  utero-vaginal 
changes  are  not  always  so  clearly  defined  in  the  first  three  months  as 
to  make  it  safe  in  every  case  to  positively  diagnosticate  pregnancy  in 
even  the  intra-uterine  form.  The  advice  to  use  the  sound  to  demon- 
strate the  vacuity  of  the  uterus  in  suspected  cases  has  been  the  cause 
of  many  needless  abortions.  Fortunately,  the  sound  often  does  no 
other  harm  than  to  add  to  our  sources  of  error.  Twice  within  a  year 
gravid  patients  have  been  sent  to  me  with  the  assurance  that  the  re- 
peated introduction  of  the  sound  had  shown  the  empty  condition  of 
the  womb.  In  one  of  them,  after  an  anaesthetic  was  given,  it  was  easy 
to  determine  the  presence  of  the  head  of  the  child  through  the  cervix 
at  the  internal  os ;  in  the  other  I  felt  perplexed,  and  asked  the  opinion 
of  Dr.  Thomas.  He  pronounced  it  an  ordinary  pregnancy,  and  the 
event  has  shown  that  he  was  correct.  Twice  within  a  year,  to  my 
knowledge,  the  abdomen  has  been  opened  in  this  city  for  supposed 
extra-uterine  gestation,  and  only  ordinary  gravidity  was  found. 

In  the  main,  our  dependence  must  be  upon  local  changes  and  local 
symptoms.  Thus  a  tubal  swelling  and  enlargement  of  the  uterus,  as- 
sociated with  suppression  of  the  menses,  often  followed  after  a  brief 
period  by  sero-sanguinolent  discharges  and  increased  flow  at  the  men- 
strual period,  with  paroxysmal  pains  radiating  from  the  side  of  the 
pelvis  upon  which  the  affected  tube  is  situated,  and  with  the  expulsion 
of  the  uterine  decidua  at  the  end  of  the  second  or  in  the  course  of  the 
third  month,  are  to  be  regarded  with  suspicion.  But  a  tubal  sac  is  the 
product  of  a  variety  of  pathological  conditions.*  The  uterine  changes 
in  early  months  are  inconstant.  These  sometimes  correspond  to  those 
of  ordinary  uterine  gestation,  but  often  there  is  neither  perceptible  en- 
largement nor  cervical  softening  to  indicate  pregnancy.  Paroxysmal 
pains  are  frequent  in  other  forms  of  tubal  disease,  and  menstrual 
disturbances  are  common  phenomena  in  uterine  derangements.     The 

*  Veit  regards  as  an  important  distinction  in  the  early  stage,  that  whereas  in 
other  forms  of  tubal  enlargement  the  swelling  may  be  hard  or  tense  or  fluctuating, 
when  due  to  an  intact  ovum  it  possesses  a  characteristic  soft  feel.  Verhandlungen 
der  Deutschen  Gesellsch.  f.  Gynaek.,  Third  Congress,  Leipsic,  1890,  p.  162. 


342  THE  PATHOLOGY  OP  PREGNANCY, 

expulsion  of  the  decidua,  though  a  valuable  sign,  is  not  of  constant 
occurrence.  In  many  tubal  abortions  the  only  symptoms  are  those  of 
pelvic  hajmatocele.  In  many  instances  of  early  rupture  of  the  tube 
with  hajmorrhage  into  the  peritoneal  cavity  there  are  no  antecedent 
symptoms,  or  only  those  of  ordinary  pregnancy.  In  reading  the  re- 
ported cases  of  the  operative  removal  of  pregnant  tubes,  it  is  surprising 
to  note  in  how  many  of  them  the  diagnosis  was  only  established  by 
the  subsequent  determination  in  the  removed  tubes  of  decidual  cells 
and  chorionic  villi.  Undoubtedly  a  probable  diagnosis  prior  to  rupture 
might  be  made  in  many  instances  if  the  patients  could  be  subjected  to 
frequent  examinations  from  the  beginning  of  the  pregnant  state,  but 
this,  in  the  nature  of  things,  is  rarely. practicable. 

In  the  intraligamentous  form  the  conditions  for  diagnosis  are  more 
favorable.  Here  gestation  is  apt  to  be  prolonged,  and  if  rupture  occurs 
between  the  folds  of  the  broad  ligament  the  hemorrhage  is  limited  in 
amount.  In  this  class  the  patients  are  apt  to  seek  early  professional 
advice,  owing  to  the  discomforts  from  which  they  suffer.  The  swelling 
at  the  side  of  the  uterus  is  easily  reached  through  the  vagina,  and  we 
have  as  distinctive  signs  a  rapidly  growing  tumor,  early  fluctuation, 
and  the  presence  of  pulsating  vessels  over  the  site  of  the  tumor. 
Bimanual  examination  under  an  anaesthetic,  especially  if  the  thumb  be 
introduced  into  the  vagina  and  two  fingers  into  the  rectum,  makes  it 
possible  to  determine  that  the  tumor  is  independent  of  the  uterus.* 

After  the  third  month  it  is  not  ordinarily  difficult  to  determine  the 
existence  of  the  pregnant  state.  Ballottement  is  usually  perceptible  at 
an  early  date,  and  the  fetal  heart  makes  the  diagnosis  certain  ;  but  the 
greatest  care  needs  to  be  exercised  in  the  examination  of  the  patient 
and  in  the  formation  of  an  opinion  concerning  the  extra-uterine  situa- 
tion of  the  ovum.  In  a  suspected  case  violence  in  the  attempt  to 
separate  the  tumor  from  the  uterus  may  cause  sac  rupture.  Grand  in 
believes  the  absence  of  contractions  when  frictions  are  applied  to  the 
sac  of  an  extra-uterine  ovum  should  prove  a  most  valuable  aid  to 
diagnosis.  Kiistner  f  curiously  enough  maintains  that  the  existence  of 
contractions  in  tubal  pregnancy  should  distinguish  them  from  other 
pelvic  growths.  Mr.  Tait  cites  as  a  misleading  condition  an  abnormal 
thinness  of  the  uterine  walls.  In  my  own  experience,  lateral  flexion  of 
the  uterus  often  simulates  ectopic  gestation  to  a  surprising  degree.  In 
these  cases  the  fundus  containing  the  ovum  lies  upon  one  side  of  the 
pelvis.     The  cervix  is  crowded  to  the  opposite  side.     Between  the  two 

*  According  to  Smolsky's  observations,  the  tube  in  the  first  two  months  is  the 
size  of  a  pigeon's  egg,  at  the  end  of  the  second  month  of  an  English  walnut,  at  two 
and  a  half  months  of  a  hen's  egg,  at  three  months  it  reaches  the  size  of  the  fist,  and 
at  four  months  the  size  of  two  fists.  Variations  may  result  from  hydramnion, 
haMnato-salpinx,  malformation,  etc.  Smolsky,  Diagnostie  et  traitement  de  la 
grossesse  tubaire,  Neuvelles  arch,  d'obstet.  et  de  gynecologie,  Dec,  1890,  p.  649. 

f  MtJLLER's,  Handbuch  der  Geburtshlilfe,  a'oI.  ii,  part  2,  p.  541. 


EXTRA-UTERINE   PREGNANCY.  343 

a  deep  sulcus  is  felt.  If  the  patient  is  hysterical,  these  deranged  rela- 
tions are  exaggerated  by  contraction  of  the  abdominal  muscles.  No 
difficulty  in  detecting  the  error  'is  experienced  when  the  patient  is 
anaesthetized,  except  in  cases  where  the  fundus  is  fixed  to  the  side  by 
adhesions.  In  two  instances  seen  by  me  the  intra-uterine  nature  of 
the  pregnancy  was  only  determined  by  the  forcible  introduction  of  the 
finger  through  the  cervix.  Cases  of  retroflexion  of  the  gravid  uterus 
with  incarceration  are  likewise  often  difficult  to  distinguish  from  extra- 
uterine pregnancy. 

The  distinction  by  physical  signs  between  the  tubal,  the  ovarian, 
and  the  secondary  abdominal  form  is  scarcely  practicable  so  long  as 
trained  anatomists  fail  to  agree  concerning  them  when  the  abdomen 
has  been  opened  and  the  organs  are  exposed  to  view. 

A  review  of  the  subject  of  diagnosis  makes  it  apparent  that  many 
cases  of  ectopic  pregnancy  present  no  symptoms  previous  to  rupture. 
In  another  class  the  existence  of  a  suspicious  tumor  with  few  or  none 
of  the  corroborative  signs  should  lead  to  a  waiting  policy,  or,  when  the 
symptoms  are  of  a  threatening  character,  to  an  explorative  laparotomy. 
It  is  well,  however,  to  remember  that  with  reference  to  this  latter  pro- 
cedure recent  popular  interest  in  abdominal  surgery  has  a  tendency  to 
invest  trifling  anomalies  occurring  in  gestation  with  a  sinister  impor- 
tance. But  there  still  remains  a  considerable  class  in  which  an  early 
diagnosis  can  be  reached  with  reasonable  certainty.* 

Treatment. — The  treatment  of  extra-uterine  fetation  varies  in  ac- 
cordance with  the  stage  of  pregnancy  and  the  condition  of  the  foetus. 
For  the  sake  of  convenience,  we  distinguish — 1.  Cases  of  early  gesta- 
tion ;  2.  Cases  of  advanced  gestation  (foetus  living) ;  3.  Cases  of  gesta- 
tion prolonged  after  the  death  of  the  foetus. 

1.  Cases  of  Early  Gestation. — The  indication  for  treatment  in  the 
early  months  varies  with  the  conditions.  If  rupture  has  occurred, 
care  should  be  employed  to  ascertain,  if  possible,  whether  the  resulting 
hsemorrhage  has  taken  place  between  the  folds  of  the  broad  ligament, 
or,  if  intraperitoneal,  whether  the  blood  is  free  in  the  abdominal 
cavity,  or  is  restricted  to  the  pelvis  by  old  adhesions.  Circumscribed 
effusions  of  blood  due  to  ruptured  tubes  do  not,  as  a  rule,  threaten  life, 
and  disappear  with  time  and  with  little  other  treatment  than  rest  in 
the  recumbent  posture. 

If  the  outpouring  of  blood  has  taken  place  primarily  into  the  ab- 
dominal cavity,  or  as  a  secondary  occurrence  after  the  giving  way  of 
the  first  barriers,  laparotomy  is  unquestionably  demanded.  While  it 
is  not  denied  that  even  in  these  extreme  cases  the  effused  blood  may 
be  circumscribed  by  an  adhesive  inflammatory  process,  and  that  a  few 
patients  may  recover  with  an  expectant  treatment,  the  waiting  policy  is 

*  Hawley  reported  in  the  N.  Y.  Med.  .Jour.,  June  16,  1888,  a  case  where  the 
diagnosis  made  previous  to  rupture  was  conftrmed  by  laparotomy. 


344  THE  PATHOLOGY  OF  PREGNANCY. 

a  gamble  with  life.  On  the  other  hand,  the  opening  of  the  abdomen 
for  the  purpose  of  removing  blood  and  clots,  and  for  the  extirpation 
of  the  tube-sac  has  been  the  means,  since  Mr.  Tait  demonstrated  the 
practicability  of  the  operation,  of  saving  multitudes  of  women  from 
impending  death.  The  operation  is  not,  as  a  rule,  difficult.  It  involves 
the  separation  of  adhesions  where  these  exist,  the  tying  of  the  pedicle, 
and  the  removal  of  the  ruptured  sac.  In  the  intraligamentous  form 
it  may  be  necessary  to  ligate  the  attached  portion  in  sections.  Where 
a  pedicle  can  not  be  readily  prepared,  Veit  recommends  the  tying  of 
the  broad  ligaments  at  the  two  extremities  of  the  sac  before  proceed- 
ing to  ligate  the  base.  Previous  to  closing  the  abdominal  incision 
great  care  should  be  taken  to  insure  the  arrest  of  haemorrhage  not  only 
from  the  stump  but  from  the  separated  adhesions. 

When  the  diagnosis  is  made  previous  to  rupture  the  choice  lies 
between  laparotomy  and  the  employment  of  measures  to  destroy  the 
life  of  the  embryo.  In  practice  the  decision  is  pretty  certain  to  be 
governed  by  other  than  theoretical  considerations.  Thus  an  experi- 
enced operator,  who  possesses  trained  assistants  and  can  command  for 
his  patient  the  surroundings  which  are  needful  for  success,  will  be  apt 
to  select  laparotomy.  The  risks  have  been  proved  to  be  small,  and  the 
patient  is  relieved  from  possible  future  troubles  due  to  retention  of  the 
products  of  conception.  But  all  men  are  not  experts  in  pelvic  surgery. 
The  danger  which  threatens  the  life  of  the  patient  is  often  imminent, 
and  assistance  from  afar  is  not  always  easy  to  obtain.  Under  these 
conditions  the  indication  for  treatment  is  plainly  the  adoption  of 
measures  to  destroy  the  life  of  the  foetus,  and  thus,  by  arresting  the 
growth  of  the  ovum,  to  diminish  the  chances  of  rupture  and  of  haemor- 
rhage. 

The  methods  which  have  heretofore  been  employed  to  destroy  the 
ovum  are  puncture  of  the  sac,  injections  of  morphia  solutions,  elytrot- 
omy,  and  the  faradic  current. 

Puncture  of  the  Sac. — Puncture  of  the  sac  is  usually  easily  effected 
by  the  introduction  of  an  exploring  trocar  through  either  the  vaginal 
or  rectal  wall.  The  operation  is  to  be  recommended  on  the  score  of 
simplicity,  but  has  not  been  attended  with  very  brilliant  results.  Re- 
coveries after  puncture  have  been  recorded  by  Greenhalgh,  Tanner, 
Stoltz,  Jacobi,  Koeberle,  and  E.  Martin  (two  cases).  Fatal  issues 
from  septicaemia  and  peritonitis  followed  puncture  in  the  hands  of 
Eouth,  J.  Y.  Simpson,  A.  Simpson,  Martin,  Braxton  Hicks,  Thomas 
(two  cases),  Conrad,  Netzel,  Hutchinson,  John  Scott,  Gallard,  and 
Depaul.  Frankel  *  withdrew  nearly  three  fifths  of  an  ounce  of  am- 
niotic fluid  from  the  sac  without  interrupting  the  course  of  preg- 
nancy. 

*  FeXnkel,  Zur  Diagnostik  und  operative  Behandlung  der  Tubenschwanger- 
schaft,  Arch.  f.  Gynaek.,  Bd.  xiv,  p.  197. 


EXTRA-UTEfllNE  PREGNANCY.  345 

Injections  of  Solutions  into  the  Sac,  designed  to  destroy  the  Fcetus 
— This  method  was  first  suggested  by  Joulin.*  He  proposed  injections 
of  sulphate  of  atropia  (one  fifth  of  a  grain  dissolved  in  a  few  drops  of 
water)  into  the  sac  by  means  of  a  long  hypodermic  syringe.  His  sug- 
gestion subsequently  was  successfully  carried  into  effect  in  two  cases 
by  Friedreich,!  of  Heidelberg.  The  needle  of  the  syringe,  he  advised, 
should  be  introduced  into  the  sac  through  the  abdominal  or  vaginal 
walls,  a  few  drops  of  fluid  should  then  be  Avithdrawn,  and  its  place 
supplied  by  the  solution  containing  the  poison  selected.  Friedreich 
employed  by  preference  a  fifth  of  a  grain  of  morphia.  The  operation 
was  repeated  every  second  day,  until  the  diminished  size  of  the  ovum 
afforded  evidence  that  the  result  sought  for  had  been  accomplished. 
T'he  operation  seemed  to  produce  but  slight  inflammatory  disturbance, 
and  the  maternal  system  did  not  feel  the  influence  of  the  narcotic. 
Eennert  \  has  since  succeeded  in  destroying  the  life  of  the  foetus  in 
the  fifth  month  of  extra-uterine  gestation  by  means  of  a  single  injec- 
tion containing  about  half  a  grain  of  morphia.  The  patient  recov- 
ered after  a  protracted  illness.  Koeberle  reported  to  the  Gynaecologi- 
cal Section  of  the  Eighth  International  Medical  Congress  at  Copen- 
hagen a  case  of  advanced  abdominal  pregnancy  where  the  child  was 
destroyed  by  morphia  injections.  The  foetus  and  placenta  were  ab- 
sorbed. The  recovery  was  complete.  Six  cases  have  been  reported  by 
Winckel,  and  one  by  Fournier.     Of  the  eleven  cases,  three  died. 

2iie  Faradic  and  Galvanic  Currents. — The  transmission  of  the 
faradic  current  through  the  ovum  has  proved  a  safe  and  efficient 
method  for  destroying  the  life  of  the  foetus  during  the  first  three 
months  of  its  existence.  The  application  consists  in  passing  one  pole 
into  the  rectum  to  the  site  of  the  ovum,  and  pres'Sing  the  other  upon 
a  point  in  the  abdominal  wall  situated  two  to  three  inches  above  Pou- 
part's  ligament.  The  full  force  of  the  current  of  an  ordinary  one-cell 
battery  should  be  employed  for  a  period  varying  from  five  to  ten  min- 
utes. The  treatment  should  be  continued  daily  for  one  or  two  weeks, 
until  the  shrinkage  of  the  tumor  leaves  no  doubt  as  to  the  death  of  the 
fcetus. 

The  successful  employment  of  the  faradic  current  in  extra-uterine 
pregnancy  we  owe  to  Dr.  J.  G.  Allen,  who  reported  two  cases  of  re- 
covery through  its  instrumentality  in  187^.  His  first  case  occurred 
in  1869,  the  second  in  1871.  Previously,  in  1859,  Burci  had  succeeded 
in  shriveling  up  the  ovum,  in  a  case  of  tubal  pregnancy,  with  the 

*  JouLix,  Traite  complet  desaccouchements,  \).  968. 

f  CoHNSTEiN,  Beitrag  zur  Schwangerschaft  ausserhalb  der  Gebarmutter,  Ai'ch.  f. 
Gynaek.,  Bd.  xiv,  p.  355.  Hennig  reports  likewise  a  case  operated  on  by  Koeberle, 
where  profuse  haemorrhage  occurred.  It  is  not  stated  whether  the  patient  recov- 
ered.    (Die  Krankheiten  der  Eileiter  und  die  Tubenschwangerschaft,  p.  138.) 

X  Rennert,  Extrauterinsehwangerschaft  im  fiinften  Monate,  Arch.  f.  Gynaek., 
vol.  xxiv,  p.  266. 


340  THE  PATHOLOGY  OF  PREGNANCY. 

galvanic  current  transmitted  through  the  tumor  by  means  of  two 
acupuncture  needles.  In  1866  Dr.  Braxton  Hicks  tried  the  faradic 
current,  but  abandoned  it  after  the  second  application.  Dr.  Allen  was 
apparently  in  no  haste  to  report  his  triumphs,  but  appears  to  have 
mentioned  them  incidentally  in  the  course  of  a  discussion  before  the 
Obstetrical  Society  of  Philadelphia.  So  little  pains  did  he  take  re- 
garding his  discovery  that  the  subject  was  nearly  forgotten,  until  a^ 
new  success  was  reported  by  Drs.  Levering  and  Landis,  of  the  Starling 
Medical  College,  in  1877.  Since  then.  Brothers*  has  collected  fifty 
cases  in  which  electricity  was  employed.  In  twenty-five  cases,  to  which 
I  can  add  a  twenty-sixth  from  my  own  practice,  and  not  included  in 
Brothers's  list,  the  health  of -the  patient  was  ascertained  to  be  good  at 
the  end  of  periods  varying  from  one  to  eight  years. 

There  were  no  evil  results  in  any  of  the  cases  traceable  to  the  elec- 
tricity. Of  the  four  fatal  ones,  in  that  of  Janvrin  rupture  of  the  tube 
had  undoubtedly  taken  place  before  the  galvanism  was  employed  ;  in 
that  of  Wylie  the  eight  months'  foetus  was  killed  by  injections  of 
morphia  into  the  sac  after  electricity  had  been  discarded ;  and  in  the 
cases  of  Duncan  and  Steavensen  and  Boulton  and  Steavensen  electro- 
puncture  was  employed, 

Against  the  method,  it  lias  been  urged  that  the  successes  reported 
are  in  themselves  evidences  of  an  erroneous  diagnosis,  that  the  faradic 
or  galvanic  current  endangers  the  integrity  of  the  tube,  and  that  the 
ovum,  after  its  vitality  has  been  destroyed,  is  liable  to  produce  suppura- 
tion. But  a  'priori  deductions  should  not  be  allowed  to  outweigh  the 
evidence  of  carefully  conducted  experiments.  It  should  be  borne  in 
mind,  however,  that  electricity. is  only  available  in  the  first  three 
months,  and  that  no  one  in  this  country  advocates  electro-puncture. f 

Cases  of  Advanced  Gestation. — After  the  third  month  it  has  now 
come  to  be  regarded  as  a  settled  rule  that  the  removal  of  the  foetus, 
the  placenta,  and  the  investing  membranes  should  be  attempted  as 
soon  as  the  diagnosis  has  been  made.  If  complete  extirpation  of  the 
sac  proves  impracticable,  it  should  be  removed  to  the  fullest  extent 
possible,  as  its  presence  when  left  in  situ  is  capable  of  leading  to  in- 
tractable sinuses  and  persistent  suppuration.  The  older  method  of 
stitching  the  sac  to  the  abdominal  wall  and  leaving  the  placenta  to 
come  away  spontaneously,  fyrnished  a  certain  number  of  favorable  re- 

*  A.  Brothers,  Subsequent  Behavior  of  Cases  of  Extra-uterine  Pregnancy 
treated  by  Electricity,  American  Jour.  Obstet.,  vol.  xxiii,  No.  2,  1890. 

f  Dr.  Franklin  H.  Martin  {vide  Goelet's  Archives  of  GyucTeeology,  1891,  p.  100) 
has  sought  to  show,  by  experiments  on  incubating  hen's  eggs,  that  the  faradic  cur- 
rent is  relatively  worthless  as  a  feticide  agent,  and  recommends  the  substitution  in 
all  cases  of  the  galvanic  current.  If  this  should  be  established  with  regard  to  the 
human  ovum,  it  must  be  confessed  it  would  greatly  weaken,  if  not  destroy,  the  argu- 
ment in  favor  of  electric  treatment,  since  nearly  all  the  reported  successes  have 
been  obtained  by  faradism. 


EXTRA-UTERINE   PREGNANCY.  347 

suits  after  the  death  of  the  child  and  the  arrest  of  the  circulation  had 
taken  place.  During  the  life  of  the  child  death  from  haemorrhage  was 
the  nearly  uniform  result.  The  conclusion  drawn  from  this  experience 
was  to  await  the  death  of  the  foetus  before  operating,  thus  exposing  the 
woman  to  the  manifold  dangei'S  arising  from  the  presence  in  the  peri- 
toneal cavity  of  a  growing  ovum,  or  of  a  sac  containing  dead  matter, 
often  in  a  state  of  putrefaction. 

But  with  clearer  anatomical  views  of  extra-uterine  pregnancy,  it  is 
getting  more  and  more  to  be  recognized  that  the  treatment  of  that 
condition  is  subject  to  the  ordinary  rules  of  abdominal  surgery. 

The  difficulties  encountered  in  the  removal  of  the  fetal  sac  are  the 
result  of  excessive  vascularity  and  extensive  adhesions,  but  these 
obstacles  to  success  have  of  late  been  found  in  many  cases  not  to  be 
insuperable.  In  the  purely  tubal  form,  where  advanced  gestation  is 
reached  without  rupture,  the  uterine  end  forms  a  pedicle  which  permits 
the  employment  of  the  ligature  en  masse.  In  this  category  should  be 
placed  the  case  of  Olshauseu,  and  probably  that  of  Eastman.  In  an 
intraligamentous  case,  Breisky  first  stitched  the  sac  to  the  abdominal 
wound  and  removed  the  foetus.  He  then  removed  the  stitches,  ligated 
the  broad  ligament  on  the  side  of  the  uterus,  and  separated  the  tumor, 
tying  at  the  same  time  any  large  vessels  found  bleeding  on  the  cut 
surface.  By  progressive  ligation  of  the  base  from  within  outward 
toward  the  pelvic  walls,  the  sac  with  the  contained  placenta  was 
detached  with  but  slight  loss  of  blood.  A  portion  of  the  sac  which 
had  grown  into  the  meso-C£ecum  was  enucleated.  Packing  with  iodo- 
form gauze  was  subsequently  resorted  to. 

Schauta  *  has  recently  reported  a  method  in  the  intraligamentous 
form  which  promises  important  future  results.  The  ovum  and  uterus 
apparently  constituted  a  single  growth.  It  was  impossible  to  ligate 
between  them.  He  succeeded,  however,  in  applying  a  double  ligature 
to  a  peritoneal  fold,  which  formed  the  residue  of  the  ligamentum 
infundibulo-pelvicum.  After  dividing  between  the  ligatures  he  got 
underneath  the  peritonaeum,  which  he  severed  by  a  circular  line  to 
the  right  uterine  cornu.  The  peritonaeum  was  then  dissected  away 
from  the  sac  wall  without  noticeable  haBmorrhage,  and  the  six  months' 
ovum  was  enucleated  entire.  Upon  detaching  the  ovum  from  the 
uterine  wall  there  was  considerable  bleeding,  requiring  the  provisional 
employment  of  compression  and  the  subsequent  use  of  the  suture. 
The  peritoneal  sac  was  then  attached  to  the  wound,  and  drained  by 
Mikulicz's  method. 

In  these  four  cases,  all  of  which  ended  in  recovery,  success  was  due 
to  the  complete  extirpation  of  the  sac.     Werthf  reported  in  1889,  to 

*  Schauta,  Beitrage  zur  Casuistik,  Prognose  und  Therapie  der  Extrauterin- 
sehwangerschaft,  Prag,  1891. 

f  Werth,   Behandlung   der  Extrauterinschwangerschaft,  Verhandlungen    der 


348  THE  PATHOLOGY  OF  PREGNANCY. 

the  Third  Congress  of  the  German  Gynaecological  Society,  nine  opera- 
tions between  1887  and  1889.  The  case  of  Schauta  increases  the  list  to 
ten.  Of  these,  eight  recovered  and  two  died.  It  was  not  possible  to 
remove  the  entire  sac  in  every  case,  but  even  partial  extirpation,  with 
employment  of  ligatures  to  the  placental  vessels  and  removal  of  the. 
placenta,  has  been  found  to  lessen  the  risks  of  the  operation  and  to 
shorten  the  period  of  convalescence. 

After  the  death  of  the  foetus  the  same  principles  hold  good  so  long 
as  the  sac  contents  have  not  been  infected.  After  putrefaction  or  pus 
formation  has  set  in  the  older  method  of  stitching  the  sac  to  the 
abdominal  incision  previous  to  opening  it  is  still  the  best.  After  the 
removal  of  the  foetus  the  placenta  should  be  left  to  separate  spon- 
taneously. While  the  detachment  is  taking  place,  it  has  been  found  that 
a  mixture  of  tannin  and  salicylic  acid  strewed  upon  the  inner  surface 
of  the  sac  is  useful  as  a  styptic  and  a  disinfectant. 

Deutschen  Gesellschaft  fiir  Gynaekologie,  3te  Kongress,  p.  175.  Other  successful 
cases  were  reported  by  Braun,  Olshausen,  John  Williams,  Lazarewitsch,  and  Treub. 
Fatal  cases  occurred  in  the  practice  of  Prochownik  and  L.  Braun. 


OBSTETEIO  SUEGEET. 


CHAPTER   XVIII. 

THE  INDUCTION  OF  PREMATURE  LABOR. 

Induction  of  premature  labor. — Indications. — Contracted  pelvis. — Habitual  death 
of  foetus. — Diseases  which  imperil  the  life  of  the  mother. — Operation. — Cathe- 
terisatio  uteri. — Intra-uterine  injections. — Rupture  of  membranes. — Mechanical 
dilatation  of  cervix. — Vaginal  douches. — Tampon. — Choice  of  methods. — Care 
of  the  child. — Artificial  abortion. 

The  induction  of  premature  labor  is  indicated  in  cases  in  which 
the  continuance  of  pregnancy,  or  delivery  at  full  term,  is  associated 
with  risks  to  mother  or  child,  or  to  both,  which  may  be  diminished 
by  bringing  pregnancy  to  a  close  at  an  early  period  after  the  foetus  is 
prepared  for  extra-uterine  existence.  The  time  at  which  the  latter 
begins  is  usually  placed  at  the  twenty-ninth  week.  As,  however,  the 
preservation  of  the  child  at  so  early  a  date  is  an  exceptional  occurrence, 
and  as  a  large  proportion  of  those  which  by  tender  care  are  made  to 
survive  the  first  danger  of  immaturity  perish  in  infancy,  commonly 
falling  a  prey  to  hydrocephalus  or  to  intestinal  derangements,  the  in- 
terests of  the  child  call  for  the  postponement  of  the  operation  as  long 
as  practicable.  Where  the  choice  lies  with  the  physician,  the  provo- 
cation of  labor  is  usually  deferred  until  the  thirty-third  or  thirty- 
fourth  week.     The  principal  indications  are  : 

1.  Moderate  Degrees  of  Pelvic  Contraction. — In  flattened  pelves 
measuring  from  two  and  three  fourths  to  three  and  one  fourth  inches, 
and  in  equally  contracted  pelves  under  three  and  one  half  inches,  the 
passage  of  a  full-term  child  is  not  impossible,  though  usually  diflScult 
and  dangerous.  By  inducing  premature  labor,  however,  owing  to  the 
smaller  size  of  the  foetus,  and  especially  to  the  increased  compressibility 
of  the  fetal  head,  we  are  enabled  to  diminish  the  mechanical  obstacles 
to  delivery,  and  thus  to  improve  the  prognosis  for  both  mother  and 
child.  To  the  mother  the  advantage  from  the  operation  is  in  all  cases 
decided,  while  to  the  child  not  much  is  gained  in  the  extreme  degrees 
of  contraction. 

The  time  at  which  gestation  should  be  interrupted  depends  upon 
the  size  of  the  pelvis  and  our  estimate  of  the  size  of  the  fetal  head. 
The  distance  from  the  lower  border  of  the  symphysis  to  the  promon- 


350 


OBSTETRIC  SURGERY, 


tory  should  be  accurately  measured,  and  the  side  walls  of  the  pelvis 
carefully  explored.  Schroeder's  measurements  show  that  the  bipari- 
etal  diameter  of  the  head  is,  between  the  twenty-eighth  and  thirty-sec- 
ond week,  about  three  and  one  fourth  inches  ;  between  the  thirty-second 
and  thirty-sixth  week,  nearly  three  and  a  half  inches ;  and  that  after 
the  thirty-sixth  week  the  increase  is  insignificant.* 

One  of  the  most  important  questions  to  be  decided  in  reference  to 
the  induction  of  labor  is  the  period  to  which  gestation  has  advanced. 
But  this,  in  the  absence  of  well-defined  signs,  it  is  easy  to  miscalculate. 
Physicians  have  been  misled  by  the  large  size  of  the  uterus  in  twin 
pregnancies  and  hydramnion  into  provoking  labor  before  extra-uterine 
existence  was  possible. 

Ahlfeld  has  shown  that  the  long  axis  of  tlie  foetus,  when  flexed  in 
utero,  is  almost  exactly  one  half  its  entire  length  in  an  extended  posi- 
tion. He  proposes  measuring  the  former  with  a  Baudelocque  pelvim- 
eter, by  placing  one  extremity  per  vaginam  upon  the  child's  head, 
and  the  other  upon  a  point  in  the  abdominal  walls  over  the  fundus  of 
the  uterus  at  which  the  breech  of  the  child  is  felt.  Very  nearly  the 
same  results  were  obtained  by  measuring  from  the  upper  border  of 
the  symphysis  in  place  of  passing  the  lower  branch  through  the  genital 
canal.  The  following  arrangement,  based  upon  his  tables,  places  be- 
fore us  in  a  practical  way  the  result  of  his  investigations,  so  far  as 
they  apply  to  the  questions  involved  in  the  induction  of  premature 
labor : f 

2.  HaUtual  Death  of  the  Foetus. — It  has  been  proposed  that,  when 
in  successive  pregnancies  the  foetus  perishes  in  utero  during  the  latter 
weeks  of  gestation,  labor  should  be  induced  after  the  period  of  viability 
has  been  reached,  but  before  the  time  at  which,  according  to  previous 
experience,  the  fatal  ending  was  to  be  expected.  This  plan  of  treat- 
ment does  not  apply  to  cases  where  death  is  due  to  syphilis,  as  a  better 

*  ScHROEDER,  Lehrbuch  der  Geburtshiilfe,  4te  Aufl.,  p.  235.  It  is  to  be  remem- 
bered that  the  biparietal  diameter  is  capable  of  a  considerable  degree  of  compres- 
sion, and  that  it  is  usually  the  bitemporal  rather  than  biparietal  diameter  which 
has  to  pass  the  narrowest  diameter  of  the  pelvis. 

f  The  arrangement  is  modified  from  one  furnished  by  Stahl  (Geburtshiilfliche 
Operationslehre,  p.  47).  Owing  to  individual  differences  in  the  length  of  the  foetus  at 
the  same  period  of  gestation,  a  considerable  source  of  error  inheres  to  the  Ahlfeld 
method  of  computation.  It  is,  however,  much  less  than  those  to  which  estimates 
based  upon  the  size  of  the  uterus  are  subject. 


Axis  of  foetus. 

Length  of  foetus. 

Biparietal  diameter. 

Duration  of  pregnancy. 

iDches. 

10 
9i 
9 

8 

Inches. 

20 
19 

18 
16 

Inches. 

H 

3 

Weeki. 

38-40 
35-37 
81-34 
29-30 

THE   INDUCTION   OF   PREMATURE   LABOR.  351 

result  is  to  be  expected  by  subjecting  both  parents  in  advance  to  anti- 
sypbilitic  treatment.  Little  benefit,  too,  would  be  derived  from  pre- 
mature labor  where  the  death  is  due  to  organic  diseases  of  the  fcetus. 
But  where  death  is  the  result  of  inanition,  dependent  upon  maternal 
anaemia,  degenerative  changes  or  faulty  development  of  the  placenta,  or 
alterations  of  the  umbilical  cord,  the  operation  is  fully  justifiable. 
With  the  difficulty,  however,  of  making  the  diagnosis  and  fixing  the 
time  when  labor  should  be  induced,  there  have  been  but  few  cases  in 
which  the  procedure  has  furnished  favorable  results. 

3.  Diseases  whicli  imperil  the  Life  of  the  Mother. — In  these  cases 
the  operation  is  primarily  performed  in  the  interests  of  the  mother, 
and  is  indicated,  therefore,  even  when  the  child  is  known  to  have  per- 
ished. Sometimes,  however,  premature  labor  becomes  a  means  of  sav- 
ing tlie  life  of  the  child,  which  shares  the  dangers  that  threaten  the 
maternal  existence.  In  this  category  belong  especially  chronic  affec- 
tions of  the  heart  and  of  the  respiratory  organs  ;  enormous  distention 
of  the  abdomen  from  multiple  pregnancy,  hydramnion,  tumors,  and 
ascites,  which  occasion  extreme  dyspnoea ;  pernicious  augemia ;  uncon- 
trollable vomiting ;  haemorrhages  from  placenta  praevia  ;  chorea ;  con- 
vulsions ;  and  nephritis,  associated  with  excessive  oedema.  In  each 
case,  however,  it  is  incumbent  to  carefully  consider  whether  the  special 
condition  is  rendered  more  threatening  by  the  existence  of  pregnancy, 
and  to  weigh  the  question  as  to  how  far,  for  the  time  being,  the  dan- 
gers are  likely  to  be  increased  by  the  progress  of  labor. 

Stehberger  has  proposed  extending  this  indication  to  cases  where 
the  preservation  of  the  mother's  life  is  hopeless,  but  in  which  prema- 
ture delivery  affords  a  chance  of  saving  the  life  of  the  child.* 

Operation. 

A  great  number  of  methods  have  been  proposed  with  a  view  to  pro- 
voke labor  prematurely.  Most  of  them,  however,  such  as  the  adminis- 
tration of  ergot,  of  quinine,  or  of  jaborandi,  the  stimulation  of  the  va- 
gina with  carbonic  acid,  frictions  of  the  breasts,  and  the  like,  do  not 
require  anything  more  than  cursory  mention.  The  following  proced- 
ures alone  possess  any  special  claims  to  favor  ; 

Catheterization  of  the  Uterus. — This  method  consists  in  the  intro- 
duction of  a  catheter,  or,  better  still,  an  elastic  bougie,  between  the  mem- 
branes and  the  walls  of  the  uterus,  and  leaving  the  instrument  in  situ 
until  active  labor  sets  in.  In  performing  the  operation  it  is  a  good  plan 
to  place  the  patient  in  a  recumbent  posture  upon  a  hard  table,  with  the 
hips  brought  near  the  edge,  and  the  thighs  well  fixed  upon  the  body. 
After  preliminary  vaginal  disinfection,  two  fingers  guide  the  point 
of  the  bougie  into  the  cervix,  the  index-finger,  passed  to  the  os  in- 

*  Stehberger,  Lex  regia  und  kiinstliche  Frlihgeburt,  Arch.  f.  Gynaek.,  Bd.  i, 
p.  465. 


352  OBSTETRIC   SURGERY. 

ternum,  then  follows  the  instrument,  and  as  it  enters  the  uterus  directs 
it  to  one  side  to  prevent  it  from  rupturing  the  membranes.  In  the 
case  of  primipar^,  preliminary  dilatation  of  the  cervix  may  be  secured, 
if  necessary,  by  the  use  of  a  sponge-tent  or  of  the  vaginal  douche.  The 
bongie  should  be  pushed  slowly  upward  with  the  disengaged  hand  and 
allowed  to  follow  its  own  course,  between  the  membranes  and  the 
uterus.  To  prevent  the  instrument  from  slipping  down,  two  inches  of 
the  extremity  may  be  left  outside  the  cervix  to  find  support  against  the 
vaginal  wall.     A  retentive  tampon  is  rarely  necessary. 

The  method  is  tolerably  certain.  In  favorable  cases  labor  follows 
its  employment  in  the  course  of  a  few  hours.  As  a  rule,  the  response  is 
more  prompt  in  multipara?  than  in  primiparae.  Sometimes,  however, 
no  action  is  set  up  during  the  first  forty-eight  hours,  or  the  pains  ex- 
cited are  of  a  cramp-like  character.  In  either  case  it  is  well  to  resort 
to  other  additional  measures.  Outside  of  unwholesome  hospitals,  the 
use  of  the  catheter  or  bougie  to  excite  labor  is  not  associated  with  any 
peculiar  risks.  The  danger  of  detaching  the  placenta  is  not  im- 
minent, if  the  instrument  be  introduced  slowly,  as,  owing  to  its  elas- 
ticity, the  bougie  tends  to  make  its  way  around  the  placental  margin. 
In  maternity  hospitals,  however,  it  may  serve  as  a  point  of  entry  for 
miasmatic  poisons,  and  thus  be  followed  by  local  irritation  and  puer- 
peral septic  affections.  Because  of  this  danger  the  solid  bougie  is  pref- 
erable to  the  hollow  catheter.  In  all  cases  only  a  perfectly  clean  and 
new  instrument  should  be  used. 

Injections  between  the  Uterus  and  Ovum.— Cohen,  of  Hamburg, 
proposed  in  1848  the  separation  of  the  membranes  by  injecting  tar- 
water  through  a  long-nozzled  syringe  made  to  penetrate  about  two 
inches  within  the  uterine  cavity.  The  nozzle  was  furnished  with  a 
rounded  extremity,  and  with  openings  upon  the  side.  He  recommended 
that  the  injection  should  be  continued  until  a  distinct  feeling  of  dis- 
tention was  experienced  by  the  patient,  which  sometimes  required  the 
employment  of  nearly  a  quart  of  the  fluid  (720  grammes).*  This  plan 
has  since  been  modified  by  the  substitution  of  an  elastic  catheter  for 
the  metallic  tube,  and  by  the  injection  of  a  few  ounces  of  simple  warm 
water  (98°  Fahr.)  in  place  of  the  aqua  picea.  In  case  of  failure 
with  a  single  injection,  it  has  been  recommended  to  repeat  the  proced- 
ure. Professor  Lazarewitch  has  demonstrated  that  the  nearer  the  irri- 
tation is  carried  to  the  fundus  the  more  certain  and  speedy  the  result. 
He  therefore  employs  a  syringe  with  a  central  opening,  and  passes  it  as 
near  to  the  fundus  as  possible,  f 

When  efficiently  performed,  the  method  possesses  the  advantage  of 
rapidly  exciting  uterine  labor-pains.  Kiinne  reports  fifteen  cases  in 
which  he  resorted  to  it  with  complete  success.     He  cautions  against 

*  Cohen,  Neiie  Ztschr.  f.  Geburtsk.,  Bd.  xxi,  p.  116. 

f  Lazarewitch,  Trans,  of  the  Obstet.  Soc.  of  London,  1868. 


THE   INDUCTION  OF  PREMATURE   LABOR.  353 

using  force  in  injecting,  and  recommends,  as  a  means  of  avoiding  the 
passage  of  air  into  veins,  the  withdrawal  of  the  catheter,  and  its  re- 
introduction,  in  case  a  haemorrhage  should  betoken  that  the  placenta 
had  been  impinged  upon.  Others  have  employed  the  method  many 
times  witli  entire  impunity.  Still,  cases  of  sudden  death  have  occurred 
during  its  use,  which  have  been  referred  to  shoclv,  to  air  getting  into 
the  uterine  sinuses,  and  to  rupture  of  the  uterus.  While,  perhaps, 
the  general  results  from  uterine  injections  have  not  been  less  satisfac- 
tory than  from  the  employment  of  other  measures  for  inducing  j)re- 
mature  labor,  the  suddenness  of  death  in  the  fatal  cases  has  had  a  deter- 
rent effect  ui)on  its  extended  employment. 

Rupture  of  the  Membranes. — This  is  the  oldest  of  all  the  methods 
now  in  use.  It  is  best  performed  by  means  of  a  simple  apparatus  de- 
vised by  the  Freiherr  Braun  von  Fernwald,  consisting  of  a  goose-quill 
sharpened  like  a  pen  and  nicked  upon  its  convex  surface  for  the  pas- 
sage of  a  uterine  sound.  Thus  mounted,  with  its  point  guarded  by 
the  sound,  it  can  be  introduced,  without  risk  to  the  maternal  tissues, 
-through  the  cervix  to  the  ovum.  Then,  by  simply  pushing  the  quill 
upward,  the  point  is  made  to  clear  the  sound  and  effect  the  puncture 
of  the  membranes.  The  method  is  certain,  though  not  always  speedy 
in  its  action.  It  is  open  to  the  objections  which  hold  good  in  all  cases 
of  premature  discharge  of  the  amniotic  fluid.  Hopkins  recommended, 
as  a  mode  to  provide  for  the  gradual  escape  of  the  liquor  amnii,  tap- 
ping the  membranes  with  a  sound  at  a  distance  from  the  os  internum. 
Rokitansky  has  shown,  from  the  statistics  of  Braun's  clinic,  that  in 
hospital  practice  puncture  of  the  membranes  is  the  safest  means  of 
inducing  premature  labor,  diminishing  as  it  does  the  chances  of  infec- 
tion, which  is  the  chief  source  of  danger  in  all  the  measures  where  the 
irritation  is  applied  directly  to  the  inner  surface  of  the  uterus.  Though 
in  private  practice  I  have  never  from  choice  selected  this  method,  I 
have  witnessed  many  cases  in  which  the  membranes  have  ruptured 
accidentally,  and  yet  have  failed  to  notice,  either  in  the  case  of  the 
mother  or  child,  the  serious  consequences  which  theory  would  lead  us 
to  apprehend.  It  is  not  adapted  for  the  higher  degrees  of  pelvic  con- 
traction or  for  cases  Avhere  speedy  delivery  is  desirable. 

Mechanical  Dilatation  of  the  Cervix. — The  dilatation  of  the  cervix 
with  sponge-tents  or  laminaria  is  rarely  resorted  to,  except  as  prepara- 
tory to  other  measures.  While  the  expansion  of  the  tent  softens  the 
cervix  and  excites  uterine  contraction,  the  effect  is  frequently  tran- 
sient. To  be  sure,  the  action  may  be  kept  up  by  a  succession  of  tents 
gradually  increasing  in  size,  but  such  a  plan  denudes  the  cervix  of  its 
epitlielium,  and  is  apt  to  lead  to  septic  infection. 

The  Barnes  dilator  is  a  most  efficient  aid  in  cases  of  induced  labor. 
It  should  be  surgically  clean,  and  before  its  introduction  both  vagina 
and  cervix  should  be  thoroughly  disinfected.  I  have  found  it  conven- 
2.3 


354  *  OBSTETRIC  SURGERY. 

lent  to  seize  it,  properly  folded,  with  a  pair  of  dressing  forceps,  by  means 
of  which  it  can  be  passed  into  the  cervical  canal.  I  then  withdraw  the 
forceps,  and  push  the  dilator  upward  with  two  fingers.  The  dilator  is, 
as  Barnes  has  termed  it,  a  water-bag.  It  should  never  be  distended 
with  air,  as  rupture  of  the  bag  in  that  case  might  be  speedily  followed 
by  the  death  of  the  patient.  As  for  the  introduction  of  the  smallest- 
sized  bag  the  cervix  requires  to  be  sufficiently  expanded  to  permit  the 
passage  of  at  least  two  fingers,  it  is  useful  chiefly  as  an  adjuvant  to 
other  plans  of  treatment.  At  first  the  dilatation  should  only  be  carried 
to  the  extent  necessary  to  render  the  cervix  tense.  When  labor  has 
fairly  begun,  the  fluid  pressure  of  the  dilator  upon  the  cervix  serves  to 
strengthen  the  uterine  action.  When  left  in  situ,  the  instrument  in- 
sures the  development  of  good  pains.  It  should,  however,  be  removed 
from  time  to  time,  if  not  forcibly  expelled  into  the  vagina,  and  carbol- 
ized  injections  should  be  employed  to  prevent  infection.  So  soon  as 
the  physiological  softening  of  the  cervix  which  results  from  labor  has 
been  effected,  rapid  dilatation  can  be  advantageously  employed.  When 
the  cervix  is  rigid,  the  rubber  bag  is  only  useful  as  a  reflex  exciter  of 
pains.  To  be  sure,  the  rigid  cervix  can  be  forcibly  dilated  to  almost 
any  extent  by  hydrostatic  pressure,  but,  as  a  rule,  it  closes  down  to  its 
original  dimensions  so  soon  as  the  pressure  is  removed.  In  rare  cases 
forcible  dilatation  may  lead  to  cervical  laceration. 

Tarnier  has  devised  a  bag  which  can  be  passed  upward  through  the 
cervix  and  distended  in  the  lower  uterine  segment.  It  serves  to  par- 
tially detach  -the  membranes,  and  excites  by  its  presence  active  uterine 
efforts.  Its  liability  to  rupture  is  the  most  serious  objection  to  its  em- 
ployment. 

The  Vaginal  Douche. — The  vaginal  douche  was  introduced  into 
practice  by  Kiwisch,  in  184G.  It  consists  in  directing  a  stream  of  tepid 
Avater  with  considerable  force  directly  against  the  cervix.  The  stream 
may  either  be  furnished  by  a  Davidson's  syringCj  or  a  continuous  cur- 
rent from  a  tube  connecting  with  a  vessel  placed  at  an  elevation  above 
the  patient  may  be  used.  The  latter  is  the  safer  method.  The  large- 
sized  fountain-syringe,  made  to  hold  a  gallon  of  water,  is  a  very  con- 
venient apparatus.  The  duration  of  each  injection  should  be  from 
ten  to  fifteen  minutes.  At  the  outset,  three  douches  in  the  twenty-four 
hours  suffice.  Subsequently  the  frequency  and  duration  should  de- 
pend upon  the  degree  of  action  excited  and  the  urgency  which  exists 
for  bringing  labor  to  a  close.  Twelve  are  about  the  average  nuniber 
of  injections  required.  In  pressing  cases  they  have  been  repeated  as 
often  as  once  in  three  to  four  hours.  The  temperature  of  the  water 
employed  should  be  about  106°  Fahr, 

In  using  the  douche  the  patient  should  be  placed  across  the  bed, 
and  an  India-rubber  sheet  should  be  so  arranged  under  the  hips  as  to 
convey  the  water  as  it  escapes  from  the  vulva  into  a  vessel  beneath. 


THE  INDUCTION    OP   PREMATURE   LABOR.  355 

Every  care  should  be  taken  to  avoid  the  introduction  of  air  into  the 
vagina,  and  at  the  beginning  of  each  douche  precautions  should  be 
adopted  to  facilitate  the  escape  of  the  fluid.  The  forcible  pressure  of 
the  stream  has  been  known  to  drive  air  contained  in  the  vagina  into 
the  cervix.  The  same  accident  has  followed  imperfection  in  the  valves 
of  the  syringe. 

The  douche  acts  by  the  M^armth  of  the  water,  by  stimulation  of  the 
lower  uterine  segment,  and  by  dilatation  of  the  vagina.  After  the 
douche  has'  been  continued  for  a  time,  the  latter  is  sometimes  distended 
so  as  to  be  nearly  in  contact  with  the  pelvic  walls. 

The  vaginal  douche  as  a  means  of  inducing  labor  has  of  late  years 
fallen  somewhat  into  disrepute.  Its  chief  recommendation  was  the 
supposed  harmlessness  of  the  procedure — a  precious  quality,  to  which 
in  reality  it  appears,  however,  to  possess  little  claim.  Numerous  cases 
have  been  reported  where  death  has  followed  the  accidental  introduc- 
tion of  air,  and  sharp  peritoneal  symptoms,  according  to  Kleinwiich- 
ter,*  have  been  known  to  result  from  the  excessive  distention  of  the 
vagina.  The  dangers  referable  to  the  latter  cause  increase  with  the 
repetitions  of  the  douche.  It  is  likewise  claimed  that  its  repetition 
tends  to  lessen  the  efficiency  of  the  uterine  contractions.  At  present 
its  employment  is  generally  restricted  to  the  preliminary  dilatation  of 
the  OS,  or  to  the  sustaining  of  the  action  of  other  measures. 

The  Vaginal  Tampon. ^ — Braun  introduced  an  India-rubber  bag,  fur- 
nished with  a  tube  and  a  metal  stop-cock,  which,  under  the  name  of 
the  col2Jeiiryntei\  still  plays  a  considerable  role  in  obstetrical  practice 
in  Germany.  When  filled  with  water  in  the  vagina,  it  formed  a  pain- 
ful and  rather  uncertain  mode  of  inducing  labor.  It  is  now  rarely 
employed  except  in  haemorrhage,  and  where  it  is  desired  to  prevent 
premature  rupture  of  the  membranes.  Care  should  be  taken  to  only 
moderately  distend  the  vagina,  and  not  to  continue  the  pressure  for 
any  lengthened  period  of  time. 

Galvanization. — Bayer  f  urges  the  constant  current  as  an  available 
means  of  exciting  labor-pains.  He  recommends  placing  the  negative 
pole  of  a  suitably  constructed  electrode  in  the  cervix,  and  the  positive 
pole  upon  the  abdomen  near  the  fundus.  Ten  to  sixteen  elements 
should  be  used  for  a  j)eriod  varying  from  ten  to  twenty  minutes.  The 
advantages  claimed  for  galvanism  are,  that  it  excites  true  pains,  that 
it  does  not  produce  strictures,  that  it  causes  the  cervix  to  soften  and 
dilate  naturally,  and  that  by  its  use  the  dangers  of  infection  are  less- 
ened. The  chief  drawback  consists  in  the  necessity  for  frequent 
repetitions  of  the  procedure  before  labor  is  brought  to  a  close.  Thus, 
in  the  six  cases  where  it  was  used  by  him,  from  two  to  thirteen  appli- 

*  Kleinwachter,  Prager  Vierteljahrsschrift,  1872,  Heft  i,  p.  56. 
f  Bayer,  Ueber  die  Bedeutung  der  Electricitat  in  der  Geburtsh.  und  Gynaek., 
vol.  xi,  p.  89. 


356  OBSTETRIC  SURGERY. 

cations  were  made,  and  the  time  from  tlie  first  application  to  the  birth 
of  the  child  varied  from  two  to  eleven  days.  As  the  effect  of  the  first 
application  is  to  soften  the  cervix  and  render  it  dilatable,  galvanism 
may  in  the  future  find  its  place  as  a  substitute  for  tents,  or  the  vaginal 
douche,  in  the  preparation  of  the  lower  uterine  segment  for  the  em- 
ployment of  accelerative  measures. 

Choice  of  Methods. — From  the  foregoing  it  will  be  seen  that  no  one 
of  the  different  proceedings  mentioned  is  entirely  free  from  objection. 
Aside,  however,  from  infection — a  danger  more  especially  dreaded  in 
maternity  hospitals — and  the  avoidable  accident  of  driving  air  into  the 
veins,  the  most  serious  difficulties  against  which  we  have  to  contend 
arise  from  the  tardy  dilatation  of  the  os  and  the  prolongation  of  labor. 
Any  of  the  methods  are  good  if  only  they  act  speedily.  It  is  advisable, 
therefore,  in  practice  to  follow  the  excellent  advice  of  Dr.  Barnes,  and 
divide  the  induction  of  premature  labor  into  two  stages,  in  the  first 
of  which  provocative,  and  in  the  second  of  which  accelerative,  meas- 
ures should  be  adopted.  In  the  former  category  should  be  placed  the 
dilatation  of  the  cervix  with  tents,  the  vaginal  douche,  and  the  cathe- 
terization of  the  uterus ;  in  the  latter,  dilatation  of  the  cervix  with  the 
rubber  bags,  rapture  of  the  membranes,  and,  in  case  of  delay,  delivery 
with  forceps  or  by  version. 

The  plan  I  have  generally  followed  consists  in  beginning  in  the  aft- 
ernoon with  the  vaginal  douche,  and  following  with  the  introduction 
of  a  solid  bougie,  to  be  left  in  the  uterus  overnight.  In  many  cases 
labor  is  excited  in  the  course  of  a  few  hours.  In  the  morning,  if  the 
process  is  delayed,  the  vaginal  douche  is  repeated.  There  are  few  cases 
in  which,  toward  the  end  of  the  twenty-four  hours,  the  cervix  is  not 
found  softened  and  well  lubricated  with  mucus.  The  dilators  should 
then  be  employed,  the  operator  taking  his  time,  as  permanent  dilata- 
tion is  the  object  sought  after.  If  the  membranes  come  down  well, 
the  dilator  may  be  removed  and  the  progress  of  the  case  left  to  Xa- 
turei '  Often  it  is  advisable  to  adopt  the  plan  of  Dr.  Barnes,  rupturing 
the  membranes  when  the  cervix  will  admit  three  or  four  fingers,  and 
then  dilating  with  the  large-sized  bag  until  the  uterus  is  opened  fully 
for  the  passage  of  the  child.  Finally,  according  to  the  conditions 
present,  the  physician  may  either  await  the  termination  of  the  labor, 
or  deliver  by  version  or  by  lightly  constructed  forceps. 

Care  of  the  Child. — Premature  infants  possess  slight  powers  of  re- 
sisting external  agencies.  The  customary  baths  should  possess  a  tem- 
perature of  100°  Fahr.,  or  very  nearly  that  of  the  amniotic  fluid.  The 
chances  of  raising  premature  infants  are  greatly  enhanced  by  feeding 
them  ^v^ith  mother's  milk.  The  artificial  maintenance  of  the  body-heat 
is  essential  to  the  preservation  of  life  in  the  early  period  of  extra-uter- 
ine existence.  In  a  rude  way  this  may  be  accomplished  by  placing 
the  child  in  warm  cotton  near  the  fire.     Before  the  thirtv-second  week 


THE  INDUCTION   OF  PREMATURE   LABOR. 


357 


the  result  in  such  cases  depends  almost  entirely  upon  the  unremitting 
watchfulness  and  zeal  of  a  devoted  mother  or  nurse.  Much  better 
results  are,  however,  obtainable  through  the  agency  of  the  contrivances 
of  Crede  and  of  Tarnier. 

Crede's  *  apparatus  possesses  the  advantage  of  cheapness  and  sim- 
plicity. It  consists  of  a  tub  made  of  copper  with  double  walls  and 
floor.  The  compartment  between  the  walls  is  capable  of  containing 
thirty-five   pints  of  water.      For  convenience  in  filling  the  compart- 


FiG.  142.— Crede's  apparatus  for  the  inainteuanee  of  the  bodylieat  of  piejnalure  and  feeble 

infants. 

ment,  a  funnel-shaped  depression,  provided  with  a  stopper,  is  furnished 
in  the  upper  margin.  A  stop-cock  below,  at  the  opposite  end,  permits 
the  water  to  be  withdrawn  at  will.  In  this  vessel  the  child  is  placed, 
enveloped  in  fine  cotton  or  soft  flannel.  The  coverings  should  reach 
to  the  brim  of  the  vessel,  the  face  of  the  child  alone  remaining  exposed. 
Every  four  hours  the  space  between  the  walls  is  to  be  filled  with  water 
heated  to  122°  Fahr.  When  the  water  is  first  introduced,  the  tempera- 
ture within  the  tub  is  about  1071°.  In  the  last  two  hours  it  sinks  to 
about  99-|-°.  In  extreme  degrees  of  prematurity,  a  more  equable  tem- 
perature may  be  maintained  by  partially  refilling  every  hour  or  every 
half-hour.  The  child  is  to  be  disturbed  as  little  as  possible.  It  should 
be  removed  only  to  be  bathed  and  to  be  placed  to  the  breast.  The 
napkins  should  be  changed,  as  far  as  possible,  within  the  vessel. 

Crede's  *  apparatus  has  been  employed  in  the  Leipsic  Maternity  for 

*  Crede,  Ueber  Erwarmungsgerathe  fiir  friihgeborene  und  schwjichliche,  kleine 
Kinder,  Arch.  f.  Gynaek.,  vol.  xxiv,  p.  128,  Berlin,  1884.  The  precise  measurements 
of  Crede's  apparatus  are  as  follows :  Length  outside,  above,  39  inches,  below,  25 
inches;  inside,  above,  23^  inches,  below,  2H  inches.  Width  outside,  above,  19 
inches,  inside,  15  inches;  inside,  above,  15  inches,  below,  11  inches. 


358 


OBSTETRIC  SURGERY. 


a  ijcrioj  of  twenty  years.  The  total  number  of  children  thus  treated 
amounted  to  six  hundred  and  seventy-eight.  The  weight  of  these 
children,  with  few  exceptions,  was  less  than  five  and  a  quarter  pounds. 
The  tota'l  mortality  was  eighteen  per  cent.  Of  twenty-four  children 
weighing  between  two  and  three  pounds,  twenty  died;  of  one  hun- 
dred and  fifteen  children  weighing  between  three  and  four  pounds, 
forty-two  died;  of  four  hundred  and  seventy-six  children  weighing 
between  four  and  five  pounds,  fifty-four  died;  while  of  fifty-two 
children  weighing  between  five  and  six  pounds  (seventeen  twins),  but 
one  died. 

The  incubator  of  Tarnier  was  first  used  at  the  Maternite,  in  1881, 
for  the  rearing  of  prematurely  born  children.  It  consists  of  a  wooden 
box  with  walls  0-10  to  0-12  centimetre  thick,  filled  in  with  sawdust  to 
prevent  loss  of  heat.  A  central  partition  divides  the  box  into  two 
compartments,  the  one  for  hot  water,  the  other  for  the  infant's  cradle. 

A  metal  case,  of  a  capacity  of 
about  seventy-one  litres,  fits 
into  the  lower  compartment, 
leaving  a  space  of  two  to 
three  centimetres  between  its 
walls  and  those  of  the  box 
for  the  free  circulation  of  air 
from  below  upward.  The 
capacity  of  the  upper  com- 
partment is  about  eighty-six 
cubic  centimetres ;  there  is 
free  circulation  of  air  be- 
tween it  and  the  lower  com- 
partment, and  it  is  in  com- 
munication with  the  outer 
air  by  means  of  two  open- 
ings— the  one,  on  its  iipper 
surface,  shut  in  by  a  double 
plate  of  glass,  the  other,  laterally,  opening  like  a  door,  and  allowing 
exit  to  the  cradle.  In  each  corner  of  this  upper  compartment  is  a 
hole  for  the  escaj^e  of  the  heated  air  from  below.  To  the  lower  com- 
partment, containing  the  hot  water,  is  attached  a  thermo-siphon  by  an 
upper  and  a  lower  tube.  When  the  lamp  under  this  siphon  is  lighted, 
the  heated  water  fiows  through  the  upper  tube  into  the  chamber,  dis- 
placing an  equal  amount  of  water  which  flows  back  to  the  siphon. 
Thus  a  current  is  established,  the  temperature  of  which  can  be  raised 
to  the  desired  point.  In  cold  weather  it  has  been  found  necessary  to 
light  the  lamp  three  times  daily,  allowing  it  to  burn  each  time  about 
two  hours.  The  lamp  should  be  extinguished  when  the  tempera- 
ture in  the  upper  compartment  is  about  two  degrees  above  the  heat 


Fig.  143.— Section  of  hospital  inc-uhator.    (Tarnier.) 


THE  INDUCTION   OF   PREMATURE   LABOR.  359 

desired.      The   registering   thermometer   may   be   laid   alongside   the 
infant.* 

In  general,  a  mean  temiierature  of  86"  Fahr.  is  sufficient,  but  90° 
is  borne  without  harm.  The  children  should  be  clothed  in  the  usual 
manner.  The  napkins  should  be  changed  five  to  six  times  daily.  A 
daily  bath  should  be  given.  Children  sufficiently  developed  to  suckle 
should  be  placed  to  the  breast.  Those  too  feeble  to  nurse  are  fed  in 
Paris  upon  asses'  milk.  The  result  of  two  years'  trial  of  the  incubator 
at  the  Paris  Maternite  Auvard  reports  as  follows :  Of  ninety-three 
healthy  premature  children,  thirty-one  died ;  of  fifty-eight  premature 
children  with  complicating  diseases,  fifteen  died.  In  comparing  these 
results,  however,  with  those  reported  by  Crede,  it  is  necessary  to  note 
that  at  the  Maternite,  in  Tarnier's  service,  only  children  weighing  four 
pounds  and  less  were  placed  in  the  incubator,  while  the  limit  in  the 
Leipsic  Maternity  was  in  general  five  and  a  quarter  pounds. 

Aktificial  Abortion. 

Artificial  abortion  is  Justifiable  whenever  it  offers  the  only  hope  of 
saving  the  life  of  the  mother.  The  morality  of  this  general  proposi- 
tion is  unquestioned.  It  is  not,  however,  by  any  means  easy  to  deter- 
mine in  a  specified  case  whether  the  conditions  which  render  the  in- 
duction of  abortion  a  duty  really  exist. 

The  principal  recognized  causes  for  the  operation  which  admit  of 
little  dispute  are :  1.  Incarceration  of  the  j^rolapsed  or  retroflexed 
uterus  when  the  dislocated  organ  can  not  be  replaced.  2.  Diseases  of 
pregnancy  which  immediately  imperil  life,  and  which  have  been  vainly 
combated  by  all  the  resources  at  our  disposal.  Qf  these  diseases  the 
most  prominent  is  uncontrollable  vomiting.  Exceptionally,  the  indi- 
cation may  arise  in  affections  of  the  heart,  lungs,  and  kidneys,  where 
the  symptoms  are  acute  and  peculiarly  threatening. 

The  justifiability  of  abortion  is,  however,  by  no  means  so  clear 
when  the  danger  to  the  mother  first  arises  after  labor  has  actually 
begun.  This  is  especially  the  case  in  extreme  degrees  of  pelvic  con- 
traction, or  where  the  presence  of  large  tumors  renders  the  parturient 
canal  impassable,  as  in  these  cases,  by  means  of  the  Ca?sarean  section, 
there  is  always  a  probability  of  saving  the  life  of  the  child,  with  a  fair 
prospect  of  preserving  the  existence  of  the  mother.  It  is  considered 
right,  under  such  circumstances,  after  a  dispassionate  and  colorless 
statement  of  the  facts,  to  leave  the  decision  to  the  mother  and  the 
friends  more  immediately  interested.  When  the  operation  is  *per- 
formed  for  contracted  pelvis,  the  following  figures  will  show  at  how 
late  a  period  it  may  be  undertaken  : 

*  Auvard,  De  la  couveuse  pour  enfants,  Arch,  de  Tocologie,  October,  1883,  p. 
577.  The  account  given  above  is  copied  from  abstract  furnished  to  the  Am.  Jour, 
of  Obstet.,  April,  1884,  by  Roliert  H.  Grandin. 


360  OBSTETRIC   SURGERY. 

Antero-posterior  diameter  of  pelvis.  Latest  perioil  for  inducing  abortion. 

1^  inch.  Beginniug  of  sixth  month. 

IJ  inch.  Beginning  of  iifth  month. 

1    incli.  Four  months  and  a  half. 

With  less  than  an  inch  the  difficulties  of  inducing  abortion  increase 
to  such  a  degree  as  to  make  the  operation  rarely  advisable,  or  indeed 
even  practicable.* 

The  induction  of  abortion  is  accomplished  by  puncturing  the  mem- 
branes with  a  uterine  sound,  or  by  dilatation  of  the  cervix  with  a 
sponge-  or  a  tupelo-tent.  In  the  early  months  dilatation  by  means  of 
a  tent  possesses  the  advantage  of  promoting  the  expulsion  of  the  ovum 
entire.  In  the  sixth  and  seventh  months  the  same  means  are  available 
that  have  been  described  in  connection  with  the  induction  of  prema- 
ture labor. 

Preparation  of  Aseptic  >Spo?iges  for  Obstetrical  Purposes.— The  sponges  em- 
ployed should  be  of  the  finest  quality.  They  should  be  pounded  with  a 
wooden  mallet  until  the  cretaceous  particles  can  no  longer  be  felt,  then 
washed  for  ten  minutes  in  a  two-per-cent  solution  of  permanganate  of  potash, 
and  washed  and  kneaded  thereafter  in  a  two-per-cent  solution  of  bioxalate  of 
potash,  till  they  become  of  a  yellowish-white  color,  and  no  more  sediment 
remains  in  the  solution.  To  remove  the  oxalic  acid,  they  should  be  washed 
in  distilled  water  until  no  reaction  is  produced  with  lime-water.  The  sponges, 
in  this  way  freed  of  inorganic  matter,  should  be  allowed  to  soak  two  days  in 
a  five-per-cent  solution  of  carbolic  acid.  The  carbolized  sponges  are  to  be 
pressed  out  two  or  three  times  in  a  ten-per-cent  solution  of  gum  arable.  A 
knitting  needle  is  passed  into  the  sponge  and  a  carbolized  thread  employed 
to  compress  it  into  a  cylindrical  shape,  care  being  taken  not  to  give  the  sponge 
a  spiral  turn  in  the  winding.  Then  withdraw  the  needle,  wrap  in  tissue  paper, 
and  leave  the  sponge  to  dry.  The  drying  usually  requires  three  or  four  days. 
Finally,  remove  the  silk,  file  away  rough  portions,  and  place  in  metal  box  for 
future  use.  (Method  of  Jungbluth,  vide  Zur  Behandlung  der  Placenta  Praevia, 
Volkmaunsche  Sammlung,  No.  235.) 

As  to  the  choice  of  time  when  the  operation  should  be  performed, 
opinions  differ.  Some  prefer  the  first  two  months,  on  account  of  the 
small  size  of  the  ovum  and  the  slight  development  of  the  fetal  tufts 
at  the  decidua  serotina.  Most  physicians  wait  till  the  first  three  or 
four  months  have  expired,  as  the  diagnosis  of  pregnancy  is  then  cer- 
tain, the  execution  of  the  operation  easy,  and  the  detachment  and  ex- 
pulsion of  the  fetal  appendages  more  complete. 

*  De  Soyre,  Dans  quels  cas  este-il  indique  de  provoquer  Favortement  ?  Paris, 

1875,  p.  68. 


FORCEPS.  361 

CHAPTER   XIX. 

FORCEPS. 

History. — Varieties  of  forceps  ;  short  forcep;^- ;  long  forceps. — Action  of  forceps. — 
Indications. — Preperations. — Forceps  at  outlet. — Operation;  introduction; 
locking  ;  tractions  ;  removal. — Forceps  at  brim  ;  operation. — Axis-traction  for- 
ceps.— Forceps  in  occipito-posterior  positions ;  in  face  presentations. 

History. — The  forceps,  it  is  well  known,  is  the  invention  of  the 
Chaniberlens.*  It  was  held  by  them  as  a  family  secret,  and  utilized 
purely  as  a  means  of  gain.  In  the  early  part  of  the  year  1670,  Hugh 
Chamberlen,  who  enjoyed  a  great  reputation  as  an  accoucheur,  went  to 
Paris  in  the  hope  of  finding  a  purchaser  for  it.  Mauriceau,  to  test 
the  value  of  Chamberlen's  pretenses,  suggested  that  the  latter  should 
attempt  the  delivery  of  a  woman  with  extreme  contraction  of  the  pel- 
vis, upon  whom  he  had  previously  decided  to  perform  the  Cgesarean 
section.  Chamberlen  declared  that  nothing  could  be  easier,  and  at  once, 
in  a  private  room,  set  about  the  task.  After  three  hours  of  vain  effort 
he  was  obliged  to  acknowledge  his  defeat.  The  woman  died ;  the  nego- 
tiations for  the  sale  were  dropped,  and  Chamberlen  returned  with  his 
secret  unrevealed  to  England.  In  1672  Chamberlen  published  a  trans- 
lation of  Mauriceau's  work  upoii  midwifery,  in  the  preface  of  which  he 
states :  "  My  father,  brothers,  and  myself  (though  none  else  in  Ettrope, 
as  I  know)  have,  by  God's  blessing  and  our  own  industry,  attained  to 
and  long  practiced  a  way  to  deliver  women  in  this  case  without  any 
prejudice  to  them  or  their  infants,  though  all  others  (being  obliged, 
for  want  of  such  an  expedient,  to  use  the  common  way)  do  or  must  en- 
danger, if  not  destroy,  one  or  both  with  hooks."  In  1688  Hugh  Cham- 
berlen went  to  Amsterdam  and  sold  his  secret  to  Roonhuysen  for  a  large 
sum,  who  in  turn  disposed  of  it  to  Ruyscli  and  others;  and,  as  late  as 
1746  it  was  the  rule  of  the  Medico-pharmaceutical  College  at  Amster- 
dam that  no  one  should  practice  midwifery  without  first  obtaining  the 
secret  measure,  which  was  imparted  by  their  examining  body  for  a  heavy 
money  consideration.  In  1753  Jacob  de  Vischer  and  Hugo  van  de  Poll, 
who  had  acquired  the  secret  from  the  daughter  of  a  former  possessor, 
made  it  public  property  ;  but  the  instrument  turned  out  to  be  the  sin- 
gle-bladed  vectis.     Whatever  doubts,  however,  this  exposure  may  have 

*  Dr.  J.  H.  AvELiNG,  in  an  essay  entitled  The  Chamberlens  and  the  Midwifery 
Forceps,  London,  1883,  concludes  that  the  inventor  proper  of  the  forceps  was 
Peter  Chamberlen  the  elder,  who  was  taken  by  his  father,  a  Huguenot  fugitive, 
from  Paris  to  London  in  1569.  Dr.  Peter  Chamberlen,  who  purchased  Mortimer 
Hall,  in  Woodham,  was  the  son  of  Peter  Chamberlen  the  younger,  a  brother  of  the 
inventoi-.  Dr.  Peter  Chamberlen's  son,  Hugh  Chamberlen.  Jr.,  was  the  translator  of 
Mauriceau's  work.  His  son,  Hugh  Chamberlen,  Jr.,  was  the  one  whose  monument 
is  seen  in  Westminster  Abbey. 


362 


OBSTETRIC  SURGERY. 


Fig.  144.— Forceps  of  Cham- 
berlen. 


cast  upon  the  nature  of  the  Chamberlen  secret  were  set  at  rest,  in  1815, 
by  the  discovery,  in  a  former  residence  of  the  family  in  Woodhara,  in 
Essex,  of  a  chest  containing,  besides  letters  and  a  variety  of  patterns  of 
the  vectis,  a  number  of  pairs  of  forceps,  fenes- 
trated, without  a  pelvic  but  with  an  excellent 
cephalic  curve.  Moreover,  Chapman,  in  a 
short  treatise  upon  midwifery,  published  by 
him  in  1733,  stated  that  "the  secret  men- 
tioned by  Dr.  Chamberlen  was  the  use  of 
forceps,  now  well  known  to  the  principal  men 
of  the  profession  both  in  town  and  country." 
And  two  years  later,  in  a  second  edition  of  his 
work,  he  published  an  engraving  of  the  instru- 
II    J  ~~\\  ment,  which  became  known  as  Chapman's  for- 

I  IjlUJj        I  ceps,  though  it  did  not  differ  from  the  one 

used  by  the  Chamberlens. 

Since  Chapman's  publication  the  modifica- 
tions made  in  the  forceps  by  obstetric  prac- 
titioners have  been  exceedingly  numerous.  Indeed,  nearly  every  man 
widely  engaged  in  midwifery  practice  finds  it  convenient  to  possess 
his  own  forceps.  With  few  exceptions,  however,  the  various  patterns 
described  by  authors  do  not  differ  materially  as 
regards  essential  principles,  but  have  each  some 
peculiarity  of  construction  which  fits  them  to 
supplement  a  personal  defect  of  the  contriver, 
or  to  meet  some  special  indication.  The  forceps 
is  by  no  means  a  perfect  instrument.  It  is  im- 
possible to  construct  it  in  such  a  way  as  to  cover 
every  need.  In  consulting  practice,  it  is  con- 
venient to  possess  a  number  of  forceps  for  dif- 
ferent emergencies.  A  good  pair  for  general  use 
is  necessarily  a  compromise  between  conflicting 
aims,  and  requires,  for  successful  use,  experience 
and  intelligence  to  correct  its  deficiencies. 

In  selecting  forceps  it  is  well  to  bear  the  fol- 
lowing points  in  mind :  We  have  first  to  distin- 
guish between  the  long  and  the  short  forceps. 

Short  Forceps.— The  original  instrument  of 
the  Chamberlens  furnishes  the  type  of  the  short 
variety.  By  referring  to  Fig.  144,  it  will  be 
seen  that  the  Chamberlen  forceps  consisted  of 
two  levers,  made  to  cross  each  other  like  a  pair 
of  scissors,  with  short  handles,  and  blades  diverging  just  beyond  the 
point  of  articulation.  The  blades  were  fenestrated,  to  lighten  the 
instrument  and  to  enable  them  to  seize  the  head  with  greater  secur- 


FlG.   145. 


-Forceps  of  Smel- 
lie. 


FORCEPS. 


363 


ity.  They  were  furnished  witli  a  cranial  curve,  as  has  been  stated, 
but  were  straight  when  viewed  in  profile.  Though  somewhat  rude 
in  appearance,  they  were  capable  of  rendering  good  service  when  the 
head  had  once  entered  the  pelvic  cavity.  Smellie,  in  place  of  the 
mortise  lock  of  the  Chamberlen  forceps,  which  required  to  be  secured 
by  tape  or  cord,  invented  the  easily  adjusted  English  lock,  and  co^■- 
ered  the  handles  with  wood  and  a  durable  coat  of  leather.  The  han- 
dles were  five  and  a  half 
inches  in  length,  and 
the  blades  six  inches. 
Short  forceps,  modified 
somewhat  from  the 
Smellie  pattern,  are 
used  by  some  prac- 
titioners at  the  pres- 
ent day.  It  has  been 
thought  an  advantage 
that  they  can  be  con- 
cealed in  the  pocket, 
and  slipped  over  the 
child's  head  without 
the  knowledge  of  the 
patient  or  of  the  as«- 
sistants.  Smellie  laid 
great  stress  upon  this 
point,  and  says  :  "  As 
women  are  commonly 
frightened  at  the  very 
name  of  an  instrument, 
it  is  advisable  to  con- 
ceal them  as  much  as 
possible  until  the  char- 
acter of  the  ojDerator  is 
fully  established."  In 
these  enlightened  days, 
however,  secrecy  is  no 

longer  advisable.  Indeed,  the  forceps  ought  never  to  be  used  without 
such  exposure  of  the  vulva  as  will  enable  the  operator  to  exercise  every 
precaution  for  the  preservation  of  the  perineum. 

Long  Forceps.— Smellie  tells  us  he  found,  in  pelves  with  jutting-in 
of  the  sacrum,  that  he  could  not  push  the  handles  far  enough  back- 
ward to  include  between  the  blades  the  bulky  part  of  the  head,  which 
lay  above  the  pubes.  He  therefore,  to  remedy  this  inconvenience, 
contrived  a  longer  pair,  curved  on  one  side  and  convex  on  the  other. 
Thus,  at  an  early  period  the  necessity  for  long  forceps  was  experienced 


Fig.  146.— Levret's  forceps. 


864 


OBSTETRIC   SURGERY, 


Smellie  was  deeply  impressed,  however,  with  the  dangers  of  high  for- 
ceps operations,  and  sought  to  diminish  the  risks  incidental  to  them 
by  making  the  handles  short,  to  free  himself,  as  he  said,  from  the 
temptation  of  using  too  great  force. 

Levret,  on  the  contrary,  contemporaneously  with  Smellie,  converted 
the  forceps  of  Chapman  into  a  powerful  tractor  and  compressor.  He 
retained  the  iron  handles,  but  roughened  the  surfaces,  and  made  them 
slightly  convex,  to  adapt  them  to  the  palms  of  the  hand.  The  articu- 
lation was  effected  by  means  of  a  pivot  and  a  mortise.  The  chief  pecul- 
iarities, however,  consisted  in  the  weight  and  the  length  of  the  instru- 
ment and  in  the  extent  of  the  pelvic  curve.     So  far  from  these  features 

proving  objectionable,  they  have 
been  substantially  retained  in  mod- 
ern French  instruments. 

The  forceps  of  Smellie  and 
Levret  are  the  two  type-forms 
from  which  are  derived  the  great 
number  of  the  models  in  vogue  at 
the  present  day. 

The  Naegele  forceps,  exten- 
sively used  in  Germany,  in  its 
main  features  resembles  the  in- 
strument of  Smellie.  It  is,  how- 
ever, two  inches  longer,  and  there 
is  less  disproportion  between  the 
length  of  the  handles  and  the 
blades.  The  upper  part  of  the 
handles  is  furnished  with  trans- 
verse shoulders,  hollowed  out  for 
the  index  and  middle  fingers  of 
the  hand  which  exerts  the  trac- 
tion force.  The  lock  is  that  of 
Bruninghausen,  and  consists  of  a  pivot,  surmounted  by  a  flat  button, 
which  fits  into  a  notch  upon  the  opposing  blade. 

The  Simpson  forceps  possesses  a  relatively  short  handle,  with  trans- 
verse shoulders,  and  indentations  for  the  fingers  of  the  under  hand. 
The  English  lock  is  improved  by  the  addition  of  knees  or  projections 
to  diminish  its  mobility.  The  cephalic  curve,  in  place  of  starting  at 
the  lock,  is  carried  away  two  and  three  eighths  inches  by  straight, 
parallel  shanks,  an  arrangement  which  makes  it  possible  to  lock  the 
instrument  outside  the  vulva  even  when  applied  to  the  head  at  the 
brim,  and  which  enables  the  operator  to  bring  the  head  to  the  floor  of 
the  pelvis  without  placing  the  vulva  upon  the  stretch.  The  pelvic 
curve  does  not  exceed  one  inch  and  a  half.  I  have  been  in  the  habit 
of  recommending  this  forceps  to  my  classes  of  medical  students,  on 


A  B  C 

FiG.  147.— Naegele's  forceps. 


FORCEPS. 


365 


account  of  the  ease  with  which  it  can  be  applied,  its  solidity,  and  the 
slight    markings  it    leaves,    under   ordinary  circumstances,   upon  the 


Fig.  148.— Simpson's  forceps. 


child's  head.     It  is,  however,  defective  in   compressive   power,   when 
such  action  is  necessary.* 

The  forceps  of  Hodge,  of  Wallace,  and  of  White  are  extensively 
used  in  this  country.  Like  those  of  French  make,  they  have  metal 
handles,  and  a  lock  composed  of  a  movable  pivot,  which  slips  into  a 
notch  at  the  moment  of  adjustment.  They  are,  however,  much 
lighter  and  of  more  graceful  outline.  The  shanks  are  long  and  super- 
imposed.    The  blades  are  provided  with  wide  fenestra?,  through  which 


Fig.  149.— Hodge's  forceps. 


the  parietal  bosses  are  intended  to  project.  I  have  tried  each  of  these 
instruments,  and,  thougli  I  cling  to  Simpson's  forceps  from  habit,  have 
found  them  extremely  serviceable. 

Finally,  in  choosing  forceps,  it  is  well  to  remember  that,  if  there 
are  none  which  are  absolutely  perfect,  there  are  few  which  are  really 
poor.  Objectionable  features  are  very  short  handles  and  thin,  spi'ingy 
blades  with  sharp  cutting  edges.  A  good  pair  of  long  forceps  renders 
the  possession  of  short  forceps  a  superfluous  luxury. 

Action  of  the  Forceps. — The  forceps  is  primarily  and  essentially  a 
tractor.  When  properly  adjusted,  it  serves  as  a  handle  by  means  of 
which  the  head  can  be  withdrawn  from  the  parturient  canal.  Many 
excellent  operators  are  in  the  habit  of  combining  with  direct  traction 

*  The  instrument-makers  of  this  city  are  accustomed  to  make  for  me  an  instru- 
ment exactly  copied  from  a  pair  of  forceps  hrovightby  nie  fiom  Edinburj^^h  in  1865. 
Many  of  the  forceps  bearing?  Simpson's  name  in  this  country  have  only  a  faint  re- 
semblance to  the  oii<rinal  model. 


3(36  OBSTETRIC  SURGERY. 

a  side-to-side  swaying  of  the  forceps-handles,  with  a  view  of  determin- 
ing the  alternate  descent  of  the  lateral  surfaces  of  the  cranial  vault. 
No  doubt  these  so-called  pendulum  movements  increase  the  extractive 
power  of  the  forceps.  The  increase  is,  however,  obtained  at  the  expense 
of  the  maternal  tissues.  If  employed,  therefore,  only  a  moderate  de- 
gree of  traction  force  should  be  exerted.  As  to  the  efficiency  of  direct 
tractions,  I  am  able  to  speak  from  experience.  At  first  insisted  upon 
by  the  Vienna  school,  they  have  found  warm  advocates  in  ]\Iatthews 
Duncan,*  of  London,  and  Albert  Smith,!  of  Philadelphia. 

The  crossing  of  the  forceps  at  the  lock  renders  it  impossible  to 
resort  to  traction  without  at  the  same  time  exercising  compression 
upon  the  child's  head.  When  the  forceps  is  applied  laterally  over 
the  parietal  bones,  moderate  pressure  is  harmless  to  the  child,  and 
undoubtedly  facilitates  in  some  degree  the  act  of  delivery.  When  the 
head  is  high  in  the  pelvis  before  rotation  is  completed,  the  lateral 
application  is  rarely  possible.  If  the  forceps  is  applied  obliquely,  with 
one  blade  over  the  side  of  the  brow  and  tlie  other  over  the  side  of  the 
occiput,  bulging  takes  place  in  the  opposite  oblique  diameter — a  result 
which  tends  to  retard  rather  than  to  aid  extraction.  Nevertheless, 
some  compressive  force  is  necessary  at  the  brim  to  seize  ihe  head  solid- 
ly, and  to  avoid  slipping  of  the  blades. 

When  the  blades  of  the  forceps  are  introduced  within  the  uterus, 
contractions  are  apt  to  be  excited.  This  so-called  dynamic  influence, 
though  an  ancillary  property  of  the  instrument,  is  often  of  consider- 
able service  in  aiding  delivery. 

Indications. — It  would  be  an  unprofitable  undertaking  to  enumerate 
all  the  conditions  which  render  forceps  advisable.  The  indications  for 
their  use  may  be  summed  up  in  two  general  propositions.  The  forceps 
is  applicable — 1.  In  cases  where  the  ordinary  forces  operative  during 
labor  are  insufficient  to  overcome  the  obstacles  to  delivery ;  2.  In  cases 
where  speedy  delivery  is  demanded  in  the  interest  of  either  mother  or 
child. 

Both  these  propositions  are,  however,  subject  to  the  limitation 
that,  in  the  selection  of  the  mode  of  delivery,  choice  should  be  made 
specially  with  reference  to  the  maternal  safety.  Fortunately,  in  tlie 
great  proportion  of  cases  the  interests  of  both  mother  and  child  are 
identical. 

Preparations  for  Forceps  Deliveries. — When  it  has  been  decided  to 
deliver  by  forceps,  it  is  a  good  plan  always  to  place  the  patient  cross- 
wise in  bed,  with  the  head  raised  by  a  pillow,  and  with  the  hips  well 
over  the  edge  of  the  bed.     To  be  sure,  many  prefer,  in  simple  cases,  to 

*  Duncan,  Against  the  Pendulum  Movement  in  working  the  Midwifery  For- 
ceps, Trans,  of  the  Obstet.  Soc.  of  Edinburgh,  vol.  iv,  p.  19.5. 

f  Smith,  The  Pendulum  Leverage  of  Obstetric  Forceps,  Trans,  of  the  Am. 
Gynaec.  Soc,  vol,  iii,  p.  235. 


FORCEPS.  3(57 

disturb  the  patient  as  little  as  possible,  and  pride  themselves  upon  being 
able  to  slip  on  the  forceps  and  deliver  without  the  seeming  of  an  opera- 
tive procedure.  This  trifling  advantage  is,  however,  more  than  coun- 
terbalanced by  the  increased  risk  of  injuring  the  vulva  and  perinaeum, 
when  the  operator  is  compelled  to  assume  a  constrained  or  awkward 
position. 

In  this  country,  as  in  France  and  Germany,  it  is  customary  to 
place  the  patient  upon  her  back  ;  whereas  in  England  she  is  made  to 
lie  upon  her  left  side.  The  difference  is  not  material.  In  the  descrip- 
tion to  follow  it  will  be  assumed  that  the  dorsal  position  is  the  only  one 
likely  to  be  selected. 

At  the  beginning,  it  is  well,  in  most  cases,  to  bring  the  patient 
under  the  influence  of  an  anaesthetic.  This  I  am  accustomed  to  do 
before  changing  the  patient's  position.  In  easy  cases  the  accoucheur 
can  administer  the  anaesthetic  before  operating,  and  then  leave  the  con- 
tinuance of  the  chloroform-  or  ether-giving  to  any  intelligent  bystander 
who  acts  under  his  supervision.  In  difficult  cases,  however,  it  is  better 
to  send  for  a  skilled  assistant  who  is  capable  of  taking  entire  charge  of 
the  anaesthesia,  that  the  operator's  attention  may  not  be  diverted  from 
the  work  he  has  in  hand. 

Before  applying  the  forceps,  care  should  be  taken  to  ascertain  the 
position  of  the  head,  and  to  make  sure  that  tlie  membranes  have  freely 
ruptured.  Forceps  applied  directly  to  the  membranes  might  do  harm 
by  causing  a  premature  detachment  of  the  placenta.  The  position  of 
the  OS  and  the  degree  of  its  dilatation  should  likewise  be  determined. 
In  excessive  anteversion  the  head  sometimes  bulges  out  the  anterior 
wall  of  the  cervix,  aiid  thins  the  cervical  tissues  to  such  an  extent  that 
the  sutures,  the  fontanelle,  and  contour  of  the  head  can  be  distinctly 
felt,  as  though  the  head  had  entered  uncovered  into  the  vagina; 
whereas,  in  fact,  the  undilated  os  is  situated  high  up,  and  with  care 
may  be  found  looking  backward  in  the  direction  of  the  sacrum.  It  is 
only  necessary  to  indicate  the  possibility  of  such  a  source  of  error  to 
insure  the  caution  necessary  for  the  avoidance  of  forceps  applications 
to  the  cervix. 

As  a  preliminary  to  all  obstetrical  operations,  both  bladder  and 
rectum  should  be  emptied.  The  vagina  should  be  washed  out  with  a 
two-per-cent  solution  of  carbolic  acid.  The  blades  of  the  forceps 
should  be  thoroughly  cleansed  in  a  warm  two-per-cent  solution  of  car- 
bolic acid  or  should  be  dipped  in  boiling  water,  and  the  hands  of  the 
operator  should  be  disinfected.  Soap  should  be  used  as  a  lubricant  for 
the  forceps  blades  and  the  hands. 

Practically  it  is  important  to  distinguish  between  forceps  opera- 
tions at  the  brim  and  those  conducted  after  the  head  has  entered  the 
cavity  of  the  pelvis.  The  latter  are  simple,  safe,  and  easy  of  accom- 
plishment, requiring  only  skill  in  the  management  of  the  perinaeum ; 


368  OBSTETRIC  SURGERY. 

while  the  former  belong  in  the  category  of  capital  operations,  and  call 
for  a  large  degree  of  patience,  experience,  and  obstetrical  tact  to  bring 
to  a  successful  issue. 

Forceps  at  the  Pelvic  Outlet.— The  special  indications  for  forceps 
when  the  head  is  low  in  the  pelvis  are  so-called  rigidity  of  the  peri- 
neum, stenosis  of  the  vaginal  orifice,  and  conditions  demanding  speedy 
delivery. 

The  condition  termed  rigidity  of  the  perinaeum  is  usually  the  sign 
of  failing  uterine  action.  So  long  as  the  labor-pains  are  good,  the  ex- 
ternal parts  progressively  soften  and  relax  in  preparation  for  the  ad- 
vancing head.  If  after  the  head  reaches  the  floor  of  the  pelvis  the 
pains  lose  their  expulsive  character,  the  perineum  may  be  rigid  simply 
because  the  ordinary  physiological  forces  which  induce  softening  are 
absent,  or,  in  case  softening  has  already  begun,  the  perineum  may 
become  rigid  from  the  sustained  pressure  to  which  it  is  subjected. 
In  either  contingency  intermiUent  tractions  made  witfi  forceps,  in 
imitation  of  the  natural  mechanism,  furnish  the  speediest  and  safest 
method  of  overcoming  the  resistance  of  the  soft  parts. 

Stenosis  of  the  vulva  is  sometimes  the  result  of  old  cicatrices. 
Oftener  it  is  found  where  there  is  faulty  direction  of  the  child's  head, 
the  vertex  bulging  the  perineum  in  place  of  serving  as  a  dilating 
wedge  to  the  vulval  orifice.  The  danger  of  central  perforation  of  the 
perineum  is  best  averted  by  applying  forceps  and  bringing  the  occi- 
put well  forward  under  the  arch  of  the  pubes.  The  commonest  condi- 
tions demanding  speedy  delivery  are  convulsions,  exhaustion,  and  fe- 
brile disturbances  in  the  mother,  and  dangers  threatening  the  life  of 
the  child.  It  is,  however,  of  great  importance  to  keep  in  mind  the 
relation  that  the  prolongation  of  the  second  stage  of  labor  bears  to 
these  very  dangers.  So  long  as  the  head  advances  through  the  par- 
turient canal  by  regular  progression,  the  vagina  pours  out  an  abundant 
secretion  of  mucus,  and  relaxation  takes  place.  If  the  advance  of  the 
head  is  arrested  from  the  dying  out  of  the  pains,  or  from  other  causes, 
the  continuous  pressure  exercised  by  the  head  upon  the  soft  parts  pro- 
duces venous  stasis,  oedema,  disappearance  of  the  secretion,  and  finally 
inflammatory  infiltration.  The  genitals  therefore  become  hot,  dry, 
swollen,  and  friable,  the  intensity  of  the  symptoms  depending  upon 
the  more  or  less  close  adaptation  of  the  head  to  the  bony  walls  of  the 
pelvic  cavity.  It  is  easy  to  understand  that  with  these  conditions  the 
temperature  rises  and  the  pulse  becomes  frequent ;  if  the  urethra  is 
compressed,  retention  of  urine  with  convulsions  may  follow ;  while,  as 
after-results,  we  may  have  phlegmasie  extending  to  the  pelvic  cellular 
tissue  and  thence  to  the  peritoneum.  Pressure  too  long  continued 
can  produce  necrosis,  and,  as  sloughing  occurs,  vesico-  and  recto- 
vaginal fistulas.  At  the  same  time  there  is  reciprocal  pressure  exer- 
cised by  the  bony  walls  upon  the  child's  head,  and  close  retraction  of 


FORCEPS.  369 

the  uterus  upon  the  foetus.  The  first  cause  may  lead  to  retarded 
heart  action  and  intra-cranial  extravasations  of  blood ;  while  the  second 
is  a  fruitful  source  of  asphyxia,  owing  to  the  diminution  of  the  mater- 
nal blood-currents  which  circulate  through  the  placenta. 

In  view  of  the  foregoing,  it  will  be  seen  that  forceps  is  not  alone 
indicated  in  the  presence  of  perils  fully  developed,  but  is  of  still 
greater  service  as  a  prophylactic  against  the  dangers  of  an  unduly 
lengthened  second  stage. 

It  is  in  vain  to  lay  down  well-defined  rules  as  to  the  precise  time 
at  which  the  forceps  should  be  applied.  Formerly  it  was  advised  to 
wait  for  the  advent  of  a  thin,  reddish-brown  discharge.  As  the  latter 
simply  consists  of  serum  commingled  with  blood  from  overstrained 
capillaries,  it  furnishes  a  sign  that  delivery  has  been  delayed  too  long. 
Some  counsel  applying  forceps  two  hours  after  the  completion  of  the 
first  stage  of  labor,  and  proclaim  longer  waiting  a  useless  barbarity. 
Clearly,  however,  it  is  not  so  much  the  length  of  the  second  stage  of 
labor  which  furnishes  the  indication  for  forceps  as  the  degree  of  the 
reciprocal  pressure  exercised  between  the  head  and  the  pelvis.  A  valu- 
able index  to  this  pressure  is  furnished  by  the  caput  succedaneum. 
In  the  second  stage,  a  scalp  tumor  of  large  circumference  can  only  be 
produced  by  the  circle  of  the  bony  pelvis.  Such  a  tumor,  increasing 
in  size,  without  any  evidence  of  progress  in  the  delivery,  is  a  signifi- 
cant evidence  of  pressure,  and  furnishes,  therefore,  the  most  reliable 
indication  for  forceps. 

Whether  the  ease  with  which  forceps  can  be  applied  at  the  outlet, 
and  the  safety  which  attends  its  employment,  justify  its  use  as  a 
means  of  saving  the  j^hysician's  time,  or  the  patient  from  an  addi- 
tional half-hour  of  suffering,  are  questions  which  are  at  least  de- 
batable. I  can  only  say  that,  with  increasing  experience,  my  own 
practice  has  grown  more  and  more  conservative,  and  my  own  belief  is 
that  true  wisdom  requires  us  to  abstain  from  even  trivial  operations  so 
long  as  Nature  is  able  to  do  her  work  without  our  assistance. 

The  operation  consists  of  four  acts,  viz. :  1.  Introduction  of  the 
blades;   2.  Locking;   3.  Tractions;   4.  Removal  of  the  instrument. 

Introduction  of  Blades. — In  introducing  the  forceps,  each  blade, 
if  a  long  one  with  pronounced  pelvic  curve,  should  be  seized  like  a 
pen  near  the  lock,  and  should  be  held  nearly  vertically,  with  the  ex- 
tremity in  correspondence  with  the  slit-like  opening  of  the  vulva.  In 
the  Simpson  forceps,  which  possesses  only  a  moderate  pelvic  curve, 
the  handle  should  be  lightly  grasped  in  the  half  hand,  and  held  at 
the  outset  nearly  parallel  to  Poupart's  ligament.  Owing  to  the  ar- 
rangement of  the  lock,  the  left  blade  should  be  passed  first.  The 
handle  should  accordingly  be  held  in  the  left  hand,  while  two  or  three 
fingers  of  the  right  hand,  inserted  between  the  head  and  the  vagina, 
serve  to  guide  and  guard  the  point  during  its  introduction.  The  pas- 
24 


370 


OBSTETRIC   SURGERY. 


sage  of  the  blade  should  take  place  only  during  the  intervals  between 
the  pains.  It  is  customary  to  pass  each  blade  at  first  opposite  the 
sacro-iliac  articulation,  and  then  to  change  the  direction  as  required, 
after  the  point  has  reached  the  Unea  terminalis. 

In  introducing  the  forceps-blades,  the  two  curves  of  the  instrument 
should  be  borne  in  mind.  By  directing  the  handle  toward  the  thigh 
of  the  mother  which  corresponds  in  name  to  the  blade,  the  latter  is 
made  to  glide  over  the  convex  surface  of  the  child's  head ;  by  sinking 
the  handle,  the  pelvic  curve  follows  the  axis  of  the  pelvis.     The  two 


Fig.  150. — Introduction  of  blades. 


movements  should  be  made  slowly  but  simultaneously,  and  under  the 
guidance  of  the  inserted  fingers.  But  slight  force  is  necessary.  The 
point  of  the  blade  should  impinge  rather  upon  the  fingers  than  upon 
the  child's  head.  When  the  left  blade  is  in  place,  the  handle  should  be 
lowered  and  intrusted  to  an  assistant.  The  right  should  be  introduced 
on  the  right  side,  under  the  guidance  of  two  to  three  fingers  of  the  left 
hand,  in  accordance  with  the  same  general  rules. 

The  cephalic  curve  of  the  forceps  is  intended  to  correspond  to  the 


FORCEPS. 


sn 


lateral  surfaces  of  the  child's  head.  When  the  rotation  of  the  occiput 
under  the  symphysis  is  complete,  it  is  only  necessary  to  sink  the 
handles  to  make  the  blades  assume  the  natural  position  over  the  parietal 
bosses.  If  the  head  is  still  in  an  oblique  diameter,  the  forceps  should 
be  applied  in  the  opposite  oblique  diameter.  When,  therefore,  the  oc- 
ciput is  left  anterior,  the  left  blade  should  be  allowed  to  remain  oppo- 
site the  sacro-iliac  articulation,  while  the  right  blade,  by  sinking  and  at 
the  same  time  rotating  the  handle,  is  swept  forward  to  the  right  ace- 
tabulum. If  the  head  is  right  anterior,  the  left  blade  is  at  once  swept 
forward  toward  the  left  acetabulum,  while  the  right  blade  is  allowed 
to  remain  opposite  the  sacro-iliac  articulation.     If  the  sagittal  suture 


Fig.  151.— Blades  of  the  Tarnier  forceps  adjusted  to  the  sides  of  the  head  at  outlet.    The  arrow 
indicates  the  direction  taken  by  the  right  blade  in  its  introduction.    (FaraboBuf  and  Varnier.) 

occupies  the  transverse  diameter,  the  forceps  should  be  applied  in  the 
oblique  diameter  of  the  same  name  as  the  side  toward  which  the  occi- 
put is  turned.  This  is  best  accomplished  by  first  applying  the  forceps 
in  the  usual  way ;  then,  leaving  the  occipital  blade  in  the  excavation  to 
the  side  of  the  promontory,  with  the  guiding  fingers  inserted  into  the 
vagina,  direct  the  frontal  blade  forward  toward  the  acetabulum.  Dur- 
ing this  manoeuvre  the  handle  should  be  held  loosely.  The  forceps  will 
seize  the  head  very  nearly  between  the  anterior  frontal  and  the  opposite 
posterior  pan'etal  protuberance.     The  direct  application  of  the  forcejas 


372  OBSTETRIC   SURGERY. 

to  the  sides  of  the  head,  with  one  blade  beneath  the  symphysis  and  the 
other  opposite  the  promontory,  has,  however,  warm  advocates.  There 
is  no  question  that  the  head  can  be  delivered  in  this  way,  but  my  own 
experience  has  been  entirely  with  the  oblique  method.* 

Loching.—^heTi  the  occiput  is  rotated  to  the  front,  and  the  blades 
are  applied  to  the  sides  of  the  head,  locking  is  a  very  simple  matter. 
The  handles  should  be  grasped  in  the  full  li^md,  with  the  thumbs 
directed  upward.  Coaptation  is  secured  by  slight  movements  of  the 
blades  as  the  operator  sinks  the  handles  downward. 

When  the  head  is  transverse  it  is  often,  on  the  contrary,  difficult 
to  bring  the  separate  parts  of  the  lock  in  apposition.  Under  such 
circumstances  no  force  should  be  used,  but  the  blades  should  be  with- 
drawn a  little,  and  the  attempt  made  to  adjust  the  lock  by  gentle  move- 
ments in  reintroducing  them. 

After  locking,  a  tentative  traction  should  be  made  to  ascertain 
whether  the  head  is  seized  securely.  In  bringing  the  blades  together 
some  caution  should  be  observed  lest  the  hair  of  the  pubes,  or  the 
labia,  become  included. 

Tractions. — The  instrument  should  be  seized  with  the  right  or 
stronger  hand,  with  the  back  of  the  hand  turned  upward.  In  forceps 
provided  with  transverse  shoulders,  the  index-finger  should  be  placed 
over  one  shoulder,  and  the  remaining  fingers  over  the  other.  The  left 
hand,  with  the  palm  upward,  seizes  the  handles  from  below  and  aids  in 
extraction.  When  the  handles  are  far  apart,  the  index-finger  of  the 
left  hand  should  be  introduced  into  the  vagina  from  time  to  time,  to 
determine  the  position  of  the  forceps-blades,  and  to  estimate  the 
amount  of  pressure  upon  the  child's  head  during  tractions. 

Steady  tractions  are  preferable  to  pendulum  or  rotary  ones.  Trac- 
tions are  most  efEective  Avhen  made  during  a  pain.  This  is  especially 
the  case  when  the  rotation  of  the  head  is  incomplete.  However,  in  the 
absence  of  pains,  it  is  often  necessary  to  use  the  forceps  as  a  substitute 
for,  instead  of  a  re-enforcement  of,  the  propulsive  action  of  the  uterus. 
Pressure  through  the  abdominal  walls  upon  the  uterus,  made  by  a 
skilled  assistant  during  tractions,  is  here,  as  in  other  obstetrical  opera- 
tions, an  adjuvant  of  great  value.  Tractions  should  not  be  too  pro- 
longed. When  not  made  in  unison  with  the  pains,  they  should  not 
exceed  one  to  two  minutes  in  duration.  The  head  should  then  be 
allowed  to  recede.  Haste  in  delivery  exposes  the  patient  to  the  dan- 
gers of  laceration  and  post-^Mrtum  hgemorrhage.  The  alternate  de- 
scent and  recession  of  the  head  soften  the  external  parts,  and  are  the 
best  means  of  overcoming  rigidity.  As  the  head  advances,  time  should 
be  given  for  the   uterus  to  retract  upon   its  contents,  for,  when  the 

*  In  a  recent  beautiful  work  entitled  Introduction  a  I'etude  clinique  et  a  la 
pratique  des  accouchements,  by  Professor  Faraboeuf  and  Dr.  Varnier,  the  direct 
application  is  strongly  favored. 


FORCEPS. 


373 


pains  are  deficient,  retraction  after  the  sndden  emptying  of  the  uteriis 
is  apt  to  be  imperfect  or  of  short  duration. 

Tractions  should  at  first  be  made  downward,  until  the  head  has 
descended  below  the  symphysis  pubis;  they  should  then  be  made  in  a 
horizontal  direction  until  the  occiput  appears  at  the  vulva.  When  in 
doubt  about  the  direction,  the  handles  should  be  held  loosely  during  a 
pain,  to  serve  as  an  index  of  the  proper  line  of  traction.  If  rotation  has 
not  previously  taken  place,  it  may  be  aided   by  the  forceps,  though 


Fig.  152.— Method  of  making  tractions. 

rotation  usually  occurs  spontaneously  as  the  head  descends.  If  the 
head  was  transverse,  the  forceps  requires  to  be  readjusted  after  rota- 
tion, either  by  removing  the  blades  and  then  reapplying  them,  or  by 
sinking  the  handle  of  the  posterior  blade  and  raising  the  handle  of  the 
anterior  one. 

When  the  parietal  bosses  are  in  the  act  of  passing  through  the 
vulva,  tractions  should  no  longer  be  made  during  the  pains.  The 
operator  should  stand  to  the  right  of  the  patient,  and  seize  the  handles 
in  the  left  hand.     During  the  intervals  of  a  pain,  by  alternately  sink- 


374 


OBSTETRIC  SUKGERY. 


ing  uiid  raising  the  handles,  the  perinaeiini  and  vulva  can  be  gradually 
difated.  So  soon  as  the  convexity  of  the  perini^um  is  marked,  and 
the  parietal  bosses  press  upon  the  commissure,  it  is  better  to  sink  the 
handles  during  a  pain,  so  as  to  flex  the  head  to  its  greatest  extent,  and 
cause  the  vertex  to  present.  When  the  vulva  is  sufficiently  dilated,  it 
is  only  necessary  to  raise  the  handles  toward  the  abdomen  to  complete 
the  extrusion  of  the  head  and  finish  the  delivery. 

Removal— Although  not  generally  recommended,  it  is  always  my 
custom  to  remove  the  forceps  so  soon  as  the  chin  can  be  reached  by  the 


:2# 


Fig.  153.— Position  of  operator  when  head  is  on  perinaeum. 


index-finger  introduced  into  the  rectum.  The  head  has  then  for  the 
most  part  emerged  from  the  pelvis,  and  its  extrusion,  if  it  does  not 
occur  spontaneously,  can  be  easily  effected  by  any  one  reasonably 
familiar  with  the  mechanism  of  parturition.  The  blades  of  the  for- 
ceps, though  of  no  great  thickness,  still  add  something  to  the  disten- 
tion of  the  vulva.  Moreover,  with  expert  management,  the  guidance  of 
the  head  through  the  vulva  and  the  utilization  of  all  unoccupied  space 
beneath  the  pubic  arch  can  be  accomplished  much  more  safely  by  the 
hand  than  by  the  most  skillful  use  of  the  forceps.  The  removal  is  ac- 
complished by  unlocking  and  reversing  the  direction  the  handles  fol- 
lowed in   their   introduction.     To  avoid    compressing   the   soft  parts 


FORCEPS. 


3T5 


against  the  rami  of  the  pubes,  I  am  accustomed  to  place  two  fingers  of 
the  unemployed  hand  upon  the  upper  border  of  the  blade,  and  use 
them  as  a  fulcrum  around  which  the  blade  should  be  rotated. 

Forceps  at  the  Brim. — The  safe  conduct  of  the  head  through  the 
pelvic  brim  by  means  of  the  forceps  is  an  achievement  which  requires 
an  accurate  appreciation  of  the  dangers  to  be  avoided  and  the  difficul- 
ties to  be  overcome.  The  forceps  as  a  means  of  accelerating  delivery 
is  sometimes  called  for  when  the  head  is  at  the  brim  in  cases  of  acci- 
dental haemorrhage,  of  placenta  prtevia,  of  eclampsia,  of  pelvic  ob- 
struction, and  in  failure  of  uterine  pains. 

So  long,  indeed,  as  the  head  is  movable  at  the  brim,  and  version  is 
practicable,  the  latter  operation  furnishes  the  safer  mode  of  delivery. 


Fig.  154.— Forceps  applied  to  head  at  brim. 

After  the  waters  have  drained  away,  and  retraction  of  the  uterus  ren- 
ders version  impossible,  a  tentative  application  of  the  forceps  may  be 
made  to  test  the  adaptability  of  the  head  to  the  pelvic  canal.  Persist- 
ent attempts  to  drag  the  head  into  the  pelvis  by  brute  force,  after 
moderate  tractions  have  failed  to  effect  an  advance,  should  be  regarded 
as  criminal,  exposing  as  they  do  the  maternal  tissues  unavailingly  to 
injuries  which  are  always  serious,  and  which  may  prove  fatal. 

When,  however,  the  head  has  become  fixed,  which  does  not  occur 
until  after  the  engagement  of  its  largest  circumference,  and  after  the 
dilatation  of  the  cervix  is  complete,  the  difficulties  of  high  forceps 
operations  are  greatly  diminished.  Still,  dangers  to  the  mother  arise 
from  the  fact  that  the  blades  have  to  be  passed  into  the  lower  segment 


376 


OBSTETRIC   SURGERY. 


'^1, 


of  tlio  uterus,  where,  owing  to  the  extreme  vuhierability  of  the  uterine 
tissues,  lesions  are  onlv  to  be  avoided  by  the  patient  carrying  out  of  a 
multitude  of  precautionary  measures ;  to  the  child,  from  the  rarity  of 
the  occasions  which  permit  the  blades  to  be  ap- 
plied to  the  sides  of  the  head,  to  which  the  ce- 
phalic curve  is  alone  adapted. 

Operation.— In  introducing,  the  forceps,  the 
tips  of  the  tingers  of  the  guiding  hand  should  be 
inserted  between  the  child's  head  and  the  cervix. 
In  this  way  we  insure  the  entrance  of  the  extrem- 
ities of  the  blades  into  the  uterus  in  place  of  into 
the  nd-de-sac  of  the  vagina.  It  is  generally  cus- 
tomary to  apply  the  forceps  to  the  sides  of  the 
pelvis,  without  reference  to  the  position  of  the 
child's  head.  As  a  rule,  under  the  conditions 
mentioned,  the  head  will  be  found  to  have  been 
seized  obliquely— i.  e.,  with  the  posterior  blade 
over  the  parietal  boss,  and  the  anterior  blade 
near  the  coronal  suture.  Thus  applied,  close 
approximation  of  the  handles  is  impossible,  and 
the  tips  are  correspondingly  separated  from  one 
another.  Considerable  compression  of  the  han- 
dles is  necessary,  therefore,  to  prevent  the  in- 
strument from  slipping,  the  degree  of  pressure 
depending  naturally  upon  the  extractive  force 
requisite  to  advance  the  head.  The  adjustment 
of  the  lock  often  requires  considerable  patience, 
and  sometimes  the  exercise  of  moderate  force  is 
necessary  to  bring  the  parts  into  juxtaposition. 

Even  when  the  instrument  has  been  applied 
according  to  the  strict  rules  of  art,  it  will  be 
found  not  infrequently  that  the  upper  border  of 
the  anterior  and  the  lower  border  of  the  pos- 
terior blade  will  project  beyond  the  tissues  of  the 
scalp,  and,  unless  managed  with  care,  the  exposed 
edges  are  liable  during  extraction  to  cut  deeply 
into  the  soft  structures  of  the  parturient  canal. 

When  the  cervix  is  only  partially  dilated,  the 
forceps  should  be  employed,  not  as  an  extractive 
instrument,  but  simply  to  bring  the  head  into 
the  cervical  canal  to  act  as  a  dilating  wedge,  by 
means  of  which  the  gradual  and  safe  expansion  of  the  os  may  be  ac- 
complished. If  the  head  be  made  to  descend  and  then  allowed  to 
recede  at  short  intervals  between  the  pains,  in  time  the  cervix  will  be 
found  to  soften  and  yield  in  the  same  manner  as  a  rigid  perinaeum ; 


Fig.    15.").— Taylin'V  nar- 
row-bladed  forceps. 


FORCEPS.  377 

whereas  the  resistance  of  an  undilated  cervix  can  only  be  overcome, 
when  violent  tractions  are  made,  by  the  production  of  lacerations  ex- 
tending to,  or  even  above,  the  vaginal  junction.  In  seeking  to  effect 
dilatation  of  the  cervix  through  the  forceps,  the  utmost  caution  shbuld, 
however,  be  observed.  At  short  intervals  the  linger  should  be  slipped 
into  the  vagina  to  note  whether  the  tension  of  the  cervix  is  raised 
during  tractions  to  dangerous  proportions.  Especial  attention  should 
be  paid  to  the  condition  of  the  parts  during  a  pain,  as,  when  the  uterus 
contracts,  the  os  externum,  which  previously  was  soft  and  dilatable, 
frequently  forms  a  sharp,  resistant  border. 

Dr.  I.  E.  Taylor  has  devised  a  long,  narrow-bladed  pair  of  forceps, 
capable  of  introduction  through  a  cervix  measuring  one  and  a  half  inch 
in  diameter,  which  he  has  used  with  advantage  in  the  manner  above 
described  at  a  very  early  stage  of  labor. 

In  cases  where  it  is  necessary  to  expedite  delivery,  the  resistance  of 
the  incompletely  dilated  os  may  be  overcome  by  a  number  of  incisions 
about  one  fourth  of  an  inch  in  depth,  made  with  a  blunt-pointed  bis- 
toury passed  between  the  cervix  and  the  child's  head.  It  is  very  rare, 
however,  that  this  otherwise  trivial  operation  is  really  called  for. 

In  drawing  the  lieM  through  the  superior  strait,  the  tractions 
should  be  made,  as  nearly  as  the  perinfeum  will  permit,  vertically 
downward.  In  doing  this,  care  must  be  taken  lest  the  pelvic  curve 
be  brought  so  far  forward  above  the  symphysis  pubis  as  to  subject  the 
maternal  tissues  to  injurious  pressure.  On  the  other  hand,  it  is  neces- 
sary not  to  prematurely  raise  the  handles  of  the  forceps,  as,  in  tliat 
ease,  the  head  is  simply  crowded  forcibly  against  the  anterior  pelvic 
wall.  The  best  means  of  avoiding  these  two  difficulties  is  to  exercise 
great  patience,  and  be  content  with  a  very  gradual  advance  of  the  head, 
as,  by  omitting  anything  like  rude  force,  the  risks  arising  from  mis- 
directed tractions  are  kept  within  the  limits  of  safety.  Many,  indeed, 
seek  to  prevent  the  anterior  pressure  of  the  forceps,  by  placing  the 
left  hand  upon  the  lock,  and  using  it  as  a  fulcrum  around  which  ro- 
tation of  the  instrument  is  effected,  xis  the  right  hand  has  then  to 
be  employed  at  the  same  time  to  make  tractions  and  to  raise  the 
handles,  the  method  requires  both  strength  and  expertness  to  be  suc- 
cessful. 

In  all  high  operations  where  the  cervix  is  sufficiently  dilated,  I  can 
not  too  strongly  recommend  the  ingenious  forceps  of  M.  Tarnier,  which, 
by  its  construction  and  action,  obviates  to  a  great  extent  the  foregoing 
objections  to  the  more  familiar  models. 

M.  Tarnier's  original  model  possessed  two  distinctive  features :  1. 
The  shanks,  in  place  of  running  forward  continuous  with  the  pelvic 
curve,  were  bent  backward,  so  that  the  handles,  when  placed  horizon- , 
tally,  occupied  a  level  three  and  a  half  inches  above  the  plane  of  tlie 
posterior  curve  of  the  blades.     This  Tarnier  curve  was  intended  to 


378 


OBSTETRIC  SURGERY. 


make  it  possible  to  adjust  tlie  blades  to  the  sides  of  the  pelvis  at  the 
brim,  without  subjectiug  the  soft  parts  in  front  or  the  periuffium  below 
to  pressure.  lu  high  operations  such  a  curve  is  of  undoubted  advan- 
tage," but  at  the  lower  strait,  unless  the  blades  are  accurately  applied  to 
the  sides  of  the  child's  head,  the  posterior  borders  of  the  blades  are  apt 
to  cut  dee])ly  into  the  vaginal  wall,  so  soon  as  the  converging  soft  parts 
embrace  tightly  the  advancing  head.  Probably  for  this  reason  Tar- 
nier,  in  his  latest  model,  has  restored  to  his  instrument  the  ordinary 
pelvic  curve.  2.  The  second  and  permanent  feature  consists  in  the 
attachment  of  two  movable  traction-rods  to  the  lower  curvature  of  the 
blades.  These  rods  are  curved,  according  to  the  model  employed,  to 
correspond  to  the  lower  border  of  the  shanks.  In  Tarnier's  instrument 
the  rods,  when  not  in  use,  are  affixed  by  projecting  pegs.  A  trans- 
verse screw,  crossing  the  handles  below  the  lock,  approximates  the 
blades  to  the  surface  of  the  child's  head.  AVhen  the  instrument  is 
adjusted,  the  outer  ends  of  the  traction-rods  are  detached  and  inserted 
into  a  socket-joint  belonging  to  a  strong  steel  bar  with  a  downward 
curve,  and  furnished  with  a  transverse  handle  which  can  be  moved  in 
any  direction  by  means  of  a  universal  joint.  Tractions  are  made  by 
means  of  this  transverse  handle  alone.  As'  the  head  descends,  the 
handles  proper  rise  upward  and  serve  as  an  index  to  show  the  direction 
in  which  the  force  should  be  exerted.  By  simply  raising  the  traction- 
rods  in  a  line  with  the  curved  shanks,  the  blades  of  the  forceps  swing 


Fig.  156.— Author's  modification  of  Tarnier's  forceps 


always  in  the  transverse  diameter,  and  the  head  follows  approximately  * 
the  axis  of  the  pelvis.  To  one  accustomed  only  to  the  familiar  forceps, 
the  facility  with  which  delivery  can  be  accomplished  by  Tarnier's  in- 
strument would  seem  hardly  credible. 

*  I  use  the  word  "approximately,"  for  my  own  experience  does  not  sustain  the 
idea  that  the  handles  of  the  forceps  furnish  an  infallible  guide  to  the  direction  in 
which  tractions  should  be  made.  In  this  respect  I  am  in  entire  agreement  with 
JT  (pl^Be«'^en-Eingangs-Zangen,  Vienna,  1885),  viz.,  that  the  advantage 
ot  the  Tarnier  principle  consists  less  in  the  mathematical  accuracy  of  the  trac- 
tions than  in  the  freedom  of  motion  that  the  traction-rods  permit  to'the  head 


FORCEPS.  379 

t 

Mr.  Stolilnianu  bus  modified  for  me  the  original  forceps  of  Tur- 
nier  by  making  tbe  blades  mucli  ligbter,  modeling  tbem  somewhat 
after  those  of  the  well-known  instrnmeut  of  Wallace.  This  alteration 
makes  their  application,  especially  in  contracted  pelves,  or  through  an 
imperfectly  dilated  os,  a  much  easier  matter.  In  place,  too,  of  the 
very  clumsy  socket-joint  into  which  the  traction-rods  are  inserted, 
he  has  substituted  the  key  arrangement  shown  in  Fig.  156,  by  means 
of  which  the  handle  can  be  adjusted  or  removed  in  a  few  seconds 
of  time. 

In  spite  of  the  example  of  the  illustrious  author  of  the  axis-traction 
principle,  I  still  cling  to  the  Tarnier  curve.  It  enables  the  operator  to 
seize  the  head  more  advantageously  at  the  brim,  and,  in  my  experience, 
it  facilitates  greatly  the  descent  of  the  head  in  the  axis  of  the  superior 
straits.  Mr.  Stohlmann  has  recently  made  for  me  a  pair  of  narrow- 
hladed  forceps  wdth  axis-traction  rods  and  Tarnier  curve,  for  eases  in 
which  the  dilatation  of  the  cervix  is  insufficient  to  permit  the  introduc- 
tion of  the  wide  blades  of  the  ordinary  instrument.  In  high  operations, 
the  operator  will  find  axis-traction  most  effective  when  the  patient  is 
j)laced  upon  ker  left  side. 

When  the  head  has  been  brought  to  the  floor  of  the  pelvis,  unless 
the  occiput  has  previously  turned  to  the  front,  it  is  a  good  j^lan  to 
remove  the  forcei)S  and  wait  for  spontaneous  rotation  to  take  place. 
If  a  reapplication  becomes  necessary,  an  instrument  Mith  the  ordinary 
curve  should  be  selected. 

Professor  Alexander  Simpson,  of  Edinburgh,  has  contrived  an  ad- 
mirable instrument  for  general  use  by  adapting  traction-rods  to  the 
popular  and  widely  employed  forceps  of  Sir  J.  Y.  Simpson.  The  rods 
as  well  as  the  handles  are  permanent  fixtures,  so  that  there  is  no  possi- 
bility of  the  parts  being  mislaid  when  required  for  service.  I  have 
given  this  instrument  an  extended  trial,  and  regard  it  as  a  most  valu- 
able addition  to  my  obstetric  equijiment.  With  the  head  in  the  jDelvic 
cavity  it  answers  every  indication.  In  high  operations,  however,  I 
have  sometimes  found  it  convenient  to  lay  it  aside  for  a  longer  forceps 
with  a  backward  curve. 

As  the  solidity  of  the  shanks  in  axis-traction  forceps  prevents  the 
blades  from  springing,  the  amount  of  pressure  upon  the  head  requisite 
to  keep  the  instrument  from  slipping  has  been  found  in  practice  not  to 
prove  an  element  of  danger  to  the  child. 

Forceps  in  Occipito-posterior  Positions. — So  long  as  the  occiput 
looks  to  the  rear,  it  is  the  rule  in  midwifery  practice  to  refrain  from 
the  use  of  forceps,  which,  of  necessity,  prevents  forward  rotation  from 
taking  place.  An  excej)tion  to  this  rule,  however,  arises  in  cases  of 
a  near  danger  to  either  mother  or  child,  demanding  speedy  delivery. 
As  attempts  to  rotate  the  occiput  around  to  the  symphysis  by  instru- 
mental means  are  rarely  successful,  it  is  advisable  under  such  circum- 


380 


OBSTETRIC   SURGERY. 


stances  to  apply  the  forceps  directly  to  the  sides  of  the  child's  head, 
aud  to  imitate  during  delivery  the  mechanism  of  labor  in  occipito-pos- 
terior  positions. 


Fig.  157. 


-Occipito-posterior  position.    Traction  in  a  downward  direction  to  secure  the  descent 
of  the  head  beneath  the  pubic  arch.    (Faraboeuf  and  Varnier.) 


The  rotation  of  the  occiput  forward  to  the  symphysis  pubis  by  forceps 
seems,  a  priori,  a  simple  matter,  aud  it  would  be  if  the  vagina  were  a  rigid 
canal  with  fixed  extremities.  In  reality  it  is  an  elastic  tube,  closely  applied  to 
the  child's  head,  and  enjoys  a  great  degree  of  mobility.  When,  therefore,  the 
head  is  turned  a  quarter-circle  within  the  pelvis,  the  soft  parts,  as  a  rule,  are 
turned  with  it.  When  the  force  is  removed,  the  vagina,  owing  to  its  resiliency, 
resumes  its  former  position,  and  generally  carries  the  head  back  to  the  original 
point  of  departure. 


^'^'pIoLT- ''■"''//'"' ">'r'''VT  position.  Descent  of  forehead  beneath  pubic  arch  completed. 
Elevation  of  liaiidle  of  forceps  to  aid  the  rotation  of  the  occiput  over  the  perinseum  (Fara- 
boeuf and  Varnier.)  ^ 


If  the  sagittal   suture   occupies  an  oblique  diameter,  the   forceps 
should  be  applied  in  the  opposite  oblique  diameter.    As  the  liead  de- 


FORCEPS.  381 

scends,  the  occiput  should  be  turned  iuto  the  hollow  of  the  sacrum. 
At  first,  tractions  should  be  made  directly  downward,  until  the  fore- 
head has  passed  under  the  pubic  arch  and  the  anterior  fontanelle 
makes  its  appearance  at  the  vulva ;  then,  by  raising  the  handles,  the 
small  fontanelle  should  be  brought  forward  to  the  commissure,  and, 
finally,  as  the  vertex  emerges  from  the  vulva,  the  handles  should 
be  slowly  depressed,  to  aid  the  movement  of  extension  by  which 
the  delivery  of  the  face  and  chin  beneath  the  pubic  arch  is  accom- 
plished. 

Forceps  in  Face  Presentations. — When  the  face  is  deep  in  the  pelvis 
and  the  chin  has  rotated  to  the  front,  forceps  applications  are  easy,  and 
do  not  differ  materially  from  those  in  vertex  presentation,  except  that 
care  should  be  taken  to  direct  the  blades  far  enough  backward  to  se- 
curely seize  the  occipital  extremity  of  the  child's  head.  Tractions 
should  be  made  in  a  horizontal  direction  until  the  chin  has  been 
brought  well  under  the  symphysis  pubis,  when  the  handles  should  be 
raised  to  lift  the  cranial  vault  over  the  perinseum.  In  oblique  mento- 
anterior positions,  Spiegelberg  advises  introducing  first  the  blade  cor- 
responding to  the  chin  (posterior  blade),  as,  in  adjusting  the  second 
blade  and  locking  the  forceps,  spontaneous  rotation  usually  takes  jjlace. 

In  deep  transverse  positions,  forceps  operations  should  be  deferred 
as  long  as  possible,  as  tardy  rotation  of  the  chin  to  the  front  is  a  physio- 
logical peculiarity  in  face  presentations.  The  forceps  should  be  ap- 
plied in  an  oblique  diameter,  with  the  concavity  of  the  blades  directed 
to  the  side  of  the  chin.  Chin  right,  introduce  the  right  blade  pos- 
teriorly, and  bring  the  left  blade  forward  to  the  left  tuberculum  ilio- 
pubicum.  An  effort  should  then  be  made  to  rotate  the  chin  to  the 
front.  If  the  attemj)t  prove  successful,  the  forceps  should  be  un- 
locked, and  the  blades  readjusted  to  the  lateral  surfaces  of  the  head. 
Tractions  when  the  face  is  transverse  should  not  be  attempted.  The 
wide  separation  of  the  blades  makes  it  necessary  to  compress  the  han- 
dles firmly  to  prevent  slipping.  When  this  is  done,  pressure  upon  the 
neck  and  thorax  is  unavoidable,  so  that  extraction  without  sacrificing 
the  life  of  the  child  is  hardly  possible. 

In  high  transverse  positions,  forceps  should  not  be  used,  as  rota- 
tion is  not  then  permissible,  and  the  blades,  apialied  to  the  neck  and 
thorax  on  the  one  side  and  upon  the  cranium  on  tlie  other,  can  not, 
for  the  reasons  just  given,  be  safely  employed  in  extraction.  The 
choice  in  such  cases,  when  speedy  delivery  is  called  for,  lies  between 
version  and  craniotomy. 

In  mento-posterior  positions,  the  rotation  of  the  chin  to  the  front 
by  repeated  applications  of  the  forceps  is  inadmissible.  In  practice, 
such  efforts  do  not  succeed,  while  they  are  calculated  to  inflict  injury 
upon  both  the  mother  and  the  child.  Usually,  if  delivery  becomes 
necessary  because  of  danger  to  the  mother,  craniotomy  should  be  re- 


382 


OBSTETRIC"  SURGERY. 


sorted  to.  Smellie,  Hicks,*  and  Braiin,  of  Vienna,  have,  however, 
each  reported  a  case  of  forceps  delivery  by  drawing  the  chm  down  over 
the  sacrum  and   perina^nm,  wlien  the  occiput  and  calvarnim  ghded 


/ 


/ 


Fig.  159. — Taylor's  method  in  mento-posterior  positions  of  the  face. 

underneath  the  pubes.  In  two  cases,  I.  E.  Taylor  f  extracted  the  chil- 
dren with  straight  forceps  after  bilateral  incision  of  the  perinaeum. 
Unfortunately,  both  children  were  dead  before  the  operation  was  un- 
dertaken. ' 


CHAPTER   XX. 
EXTRACTION  IN  FOOT  AND  BREECH  PRESENTATIONS. 

Extraction  in  pelvic  presentations. — Attitude  of  the  physician. — Prognosis. — Posi- 
tion.— Extraction  of  trunk. — Extraction  by  the  feet ;  by  the  breech. — Manage- 
ment of  the  cord. — Liberation  of  the  arms. — Exceptional  cases. — Extraction  of 
the  head. — Smellie's  method. — Veit's  method. — Head  at  brim. — Prague  method. 
— Forceps  to  the  after-coming  head. 

We  have  already  seen,  in  studying  the  management  of  breech  pres- 
entations, that  the  attitude  of  the  physician  during  delivery,  so  long 

*  Hicks,  On  Two  Cases  of  Face  Presentations  in  the  Mento-Posterior  Position. 
Trans,  of  the  Obstet.  Soc.  of  London,  vol.  vii,  p.  56.  Hicks  likewise  reports  the 
cases  of  Smellie  and  Braun. 

f  Taylor,  On  the  Spontaneous  and  Artificial  Delivery  of  the  Child  in  Face 
Presentations,  N.  Y.  Med.  Jour.,  Nov.,  1869. 


EXTRACTION  IN    FOOT   AND   BREECH    PRESENTATIONS.      3S3 

as  no  immediate  danger  threatens  either  the  mother  or  the  child, 
should  be  one  of  watchfnl  observation.  As  a  rule,  the  results  to  the 
child  are  unquestionably  more  favorable  when  Xature  does  her  work 
unaided.  If,  however,  there  be  any  faltering  in  the  natural  forces,  the 
physician  should  be  in  readiness  to  avert,  by  prompt  interference,  the 
perils  which  in  pelvic  presentations  are  associated  with  delay.  When 
an  artificial  breech-presentation  has  been  produced  by  internal  version, 
immediate  extraction  is  usually  advisable,  as  the  act  of  version,  when 
the  entire  hand  has  to  be  introduced  into  the  uterus,  is  apt  to  com- 
promise the  safety  of  the  child. 

Strong  uterine  contractions,  a  roomy  pelvis,  a  dilated  cervix,  and 
a  relaxed  state  of  the  vaginal  outlet,  are  conditions  highly  favorable  to 
the  success  of  the  operation.  Under  such  circumstances,  artificial  de- 
livery can  be  performed  with  celerity  and  ease.  But  these  conditions, 
however  desirable,  are  not  absolutely  indispensable.  Thus,  extraction 
is  rarely  indicated  if  the  pains  are  good  ;  it  is  often  necessary  to  deliver 
before  the  cervix  has  reached  the  desirable  degree  of  dilatation ;  and 
it  is  possible  to  drag  the  head  of  the  child  through  a  moderately  con- 
tracted pelvis  without  inflicting  upon  it  any  permanent  injury.  There 
is  always  danger,  however,  in  the  last  two  cases,  of  not  being  able  to 
extract  the  child  rapidly  enough  to  save  it  from  asphyxia. 

The  prognosis  for  the  mother  is  generally  favorable.  Still,  lacera- 
tions are  apt  to  follow  the  forcible  delivery  of  the  head  through  the 
undilated  cervix. 

Extraction  is  commonly  performed  with  the  patient  on  her  back. 
In  easy  cases  she  may  occupy  the  usual  position  in  bed,  while  the  phy- 
sician places  himself  at  her  side.  If  difficulty  is  anticipated,  the  pa- 
tient should  be  placed  crosswise,  with  hips  raised  by  a  hard  cushion, 
and  brought  over  the  edge  of  the  bed ;  or,  better  still,  may  be  placed 
upon  a  table,  as  the  operator  is  then  enabled  to  draw  downward  in  the 
direction  of  the  superior  strait  without  kneeling  before  her.  It  is  de- 
sirable to  have  two  assistants  to  hold  the  patient's  knees.  To  one  of 
these  should  likewise  be  assigned  the  duty  of  making  firm  pressure, 
during  extraction,  upon  the  fundus  of  the  uterus.  If  anaesthesia  is 
thought  necessary,  a  third  assistant  will  be  required.  The  question  of 
anaesthesia  is  not  always  easy  to  decide.  Useful  in  unruly  patients, 
and  where  the  entire  hand  must  be  passed  into  the  vagina,  its  occa- 
sional suspensive  action  upon  the  uterine  pains  and  the  loss  of  the 
co-operation  which  intelligent  patients  are  capable  of  affording  are 
alloys  to  its  beneficent  action  in  stilling  pain.  My  preference  is  to 
anaesthetize  lightly  at  first,  and  then  be  guided  by  events  as  to  whether 
the  insensibility  shall  be  subsequently  made  complete,  or  the  patient 
be  allowed  to  return  to  partial  consciousness. 

As  in  all  obstetrical  operations,  in  addition  to  the  usual  aseptic  pre- 
cautions, care  should  be  taken  to  insure  the  emptying  of  the  bladder 


3g^  OBSTETRIC   SURGERY. 

and  rectum,  and  the  operator  should  have  iu  readiness,  in  case  of  need, 
forceps,  a  soft  fillet,  Avarni  napkins,  hot  and  cold  water,  and  a  small 
English  (No.  7)  catheter,  for  use  should  the  child  be  born  in  a  state  of 
partial  asphyxia. 

The  operation  is  divisible  into  three  acts :  1.  Extraction  of  the 
trunk  as  far  as  the  shoulders;  2.  Extraction  of  the  arms;  3.  Ex- 
traction of  the  head. 

First  Act:    Extraction  of  the  Trunk  to  the  Shoulders. 

The  extraction  of  the  trunk  should  take  place  slowly,  with  pauses 
between  the  tractions,  in  imitation  of  the  uterine  expellent  forces. 
Tractions  are  best  made  during  the  pains  only,  when  the  latter  do  not 
recur  at  too  long  intervals.  It  is  desirable  that  the  uterus  be  closely 
retracted  upon  the  child  during  the  entire  period  of  its  expulsion. 
Where  this  does  not  occur,  the  arms  are  liable  to  be  brushed  upward 
to  the  sides  of  the  child's  head,  the  chin  to  become  extended,  and  the 
mechanism  of  the  head-delivery  to  be  disturbed.  Hemorrhage,  too, 
is  more  likely  to  follow  hasty  delivery  than  where  the  uterus  has  had 
time  to  pass  slowly  into  a  state  of  complete  retraction.  When,  there- 
fore, it  is  necessary  to  extract  during  the  intervals  between  the  pains, 
firm  pressure  should  be  made  upon  the  uterus  through  the  abdominal 
walls,  so  as  to  maintain  them  in  close  contact  with  the  foetus.  Steady 
tractions  are  preferable  to  pendulum  movements.  Tractions  should  be 
made  downward  and  backward,  in  the  direction  of  the  superior  strait, 
until  the  breech  meets  with  the  resistance  of  the  floor  of  the  pelvis. 

These  general  rules  are  applicable  to  every  case  of  extraction. 
Special  differences  of  procedure  result  from  the  presentation  of  one  or 
both  feet,  and  of  the  entire  breech. 

Extraction  by  the  Feet. — If  a  single  extremity  presents,  the  foot 
should  be  seized  between  the  middle  and  index  finger,  with  the  thumb 
upon  the  sole,  or  across  the  instep.  It  is  not  necessary  to  go  in  search 
of  the  second  foot,  unless  it  crosses  the  first,  or  is  reflected  upward  over 
the  child's  back.  When  the  leg  is  drawn  outside  of  the  vulva,  it 
should  be  wrapjsed  in  a  warm  napkin,  and  grasped  by  the  entire  hand. 
Always,  in  seizing  a  limb,  the  thumb  should  be  directed  upward  and 
applied  to  the  dorsal  surface.  The  napkin  serves  partly  to  prevent  the 
hand  from  slipping,  partly  to  protect  the  surface  from  air,  which  at 
times  is  capable  of  exciting  reflex  respiratory  movements.  Tractions 
should  be  made  downward,  to  avoid  friction  at  the  symphysis  pubis. 
Until  the  pelvis  is  delivered,  the  child  should  be  seized  as  near  the 
maternal  parts  as  possible.  The  hand,  therefore,  should  be  shifted  u])- 
ward  as  the  limb  is  drawn  out  of  the  vulva.  Whichever  extremity  is 
seized  rotates  forward  under  the  symphysis  pubis  during  extraction. 
For  this  reason,  when  an  election  is  practicable  it  is  desirable  to  draw 
upon  the  anterior  leg,  since  owing  to  the  slight  amount  of  rotation 


EXTRACTION  IX  FOOT  AND  BREECH  PRESENTATIONS.   385 

involved  there  is  less  likelihood  of  derangement  of  shoulder  and  head 
mechanism  as  these  engage  in  the  pelvis.  So  soon  as  the  breech 
reaches  the  pelvic  floor,  traction  should  be  made  more  in  an  upward 
direction,  to  facilitate  the  passage  of  the  buttocks  over  the  perinaeum. 
After  the  breech  has  cleared  the  vulva,  the  index-finger  of  the  free 
hand  should  be  carefully  inserted  into  the  fold  of  the  posterior  thigh, 
while  the  thumbs  of  both  hands  are  placed  upon  the  sacrum.  During 
the  subsequent  extraction  of  the  trunk  the  lower  leg  falls  from  the 
vagina  without  special  assistance. 

If  both  extremities  present,  they  should  be  seized  so  that  the  mid- 
dle finger  is  placed  between  the  feet,  while  the  index-  and  ring-fingers 
encircle  the  external  malleoli.  After  they  have  passed  sufficiently  far 
outside  the  vulva,  the  left  leg  should  be  seized  with  the  left  hand  and 
the  right  foot  with  the  right  hand.  During  extraction  the  normal 
rotation  of  the  child  may  be  aided  by  dragging  with  somewhat  greater 
force  upon  the  limb,  which  should  be  turned  to  the  front. 


Fig.  160.— Method  of  seizing  the  breech. 

Extraction  by  the  Breech. — When  the  breech  alone  presents,  with 
both  extremities  reflected  upward  parallel  to  the  anterior  surface  of  the 
25 


3g(j  OBSTETRIC  SURGERY. 

child,  spontaneous  delivery  is  sometimes,  as  pointed  out  by  Tarnier, 
prevented  by  the  fact  that  the  extended  limbs  act  as  splints  which  in- 
terfere with  the  lateral  flexion  of  the  trunk,  and,  consequently,  with  its 
accommodation  to  the  curve  of  the  parturient  canal.  If,  m  pure 
breech  cases,  obstetrical  aid  becomes  necessary,  the  operator  is  em- 
barrassed by  the  absence  of  a  natural  handle  by  means  of  which  extrac- 
tion can  be  effected. 

Theoretically,  cephalic  version  by  external  manipulations,  performed 
during  the  latter  part  of  pregnancy  or  in  the  early  stages  of  labor, 
most  completely  fulfills  the  required  indications,  viz.,  the  saving  of  the 
child  with  the  least  possible  risk  to  the  mother.  That,  in  cases  where 
the  breech  is  not  engaged  in  the  pelvic  cavity  and  the  membranes  are 
intact,  external  version  may  be  successfully  accomplished,  has  been 
shown  by  Mattel,  Hegar,  and  Pinard.  Tarnier  at  first  opposed  the 
measure  on  the  ground  of  its  impracticability  and  the  risk  of  rupturing 
the  membranes  before  the  version  was  completed,  thus  converting  a 
breech  into  a  shoulder  presentation,  but  more  recently  has  practiced 
the  procedure  in  many  cases  without  inconvenience  to  the  mother  or 
child.*  Its  successful  performance  presupposes  a  relatively  consider- 
able quantity  of  amniotic  fluid,  the  absence  of  reflex  irritability  in  the 
patient,  and  experience  on  the  part  of  the  operator  in  mapping  out 
the  fretus  through  the  abdominal  wall.  Ahlfeld  f  advises  that  in  pri- 
mipara?  the  hand  be  introduced  immediately  after  the  rupture  of  the 
membranes,  or  at  least  while  the  introduction  is  still  practicable,  and 
that  the  anterior  extremity  be  brought  down  as  a  prophylactic  measure, 
leaving  the  child  to  be  expelled  subsequently  by  the  natural  forces. 
The  hand  should  be  passed  over  the  anterior  surface  of  the  child  to  the 
knee ;  the  thumb  should  then  be  placed  in  the  popliteal  space,  while 
four  fingers  grasp  the  leg,  flex  it  upon  the  thigh,  and  draw  it  down 
into  the  vagina.  The  operation  is  facilitated  by  placing  the  patient 
upon  the  side  to  which  the  chiUrs  feet  are  turned.  But  Kiistner,  in 
common  Avith  most  authorities,  objects  that  the  mancBuvre  is  apt  to 
weaken  the  uterine  contractions  and  to  favor  prolapse  of  the  cord.  In 
others  words,  in  order  to  avert  a  remote  danger,  a  near  one  quite  as 
serious  is  invited. 

If,  however,  it  becomes  necessary  to  expedite  delivery,  without 
doubt,  in  all  cases  where  it  is  possible  to  pass  the  hand  to  the  fundus 
and  bring  down  an  extremity  without  imperiling  the  uterine  struct- 
ures, this  method  should  be  employed  by  preference.  But  emergencies 
rarely  arise  before  the  breech  has  descended  into  the  pelvic  cavity. 
Most  frequently  the  membranes  have  already  ruptured,  and  the  uterus 
has  retracted   upon   the   foetus.     Under   such   conditions   the    intro- 

*  Ollivier,  De  la  conduite  a  tenir  dans  la  presentation  de  I'extremite  pelvienne. 
Mode  des  fesses,  p.  lO-S,  Paris,  1883. 

f  Ahlfeld,  Arch.  f.  Gynaek.,  vol.  v.  p.  174,  Berlin,  1873. 


EXTRACTION  IN  FOOT  AND  BREECH  PRESENTATIONS.   387 

ductiou  of  the  hand  and  forearm  over  the  anterior  surface  of  the  child 
to  the  fundus  becomes  a  serious  undertaking,  and  may  lead  to  uterine 
rupture.  Traction  upon  the  extremity  seized  is  not  always  followed 
by  its  descent,  and  where  force  is  used  the  descent  may  be  accomplished 


Fig.  161.— Method  of  seizing  both  extremities. 

at  the  expense  of  a  fracture.  To  be  sure,  the  manoeuvre  is  supported 
by  the  high  authority  of  Dr.  Barnes.  "  The  wedge  formed  by  the  ex- 
tended legs  and  the  upper  part  of  the  trunk  must,"  he  says,  "  in  some 
instances  at  least,  be  decomposed  Ijefore  delivery  can  be  effected."  He 
recommends  complete  anaesthesia,  support  of  the  fundus,  gentleness  in 
passing  the  breech  at  the  brim,  and  applying  the  fingers  to  the  instep. 
But  Barnes  does  not  conceal  the  difficulties  of  the  operation,  nor  the 
address  requisite  for  its  successful  employment,  and  many  accoucheurs, 
less  fortunate,  have  recorded  their  failures  to  decompose  the  wedge  in 
the  manner  advised.  In  a  few  cases,  influenced  by  Barnes's  teachings, 
I  have,  under  most  difficult  conditions,  succeeded  in  bringing  down  a 
foot ;  nevertheless,  I  would  advise  the  utmost  caution  in  practicing  the 
method,  and  that  in  all  cases  the  operator  desist  the  moment  address 
fails  and  force  becomes  necessary.     If,  at  the  time   intervention   be- 


ggg  OBSTETRIC   SURCxERY. 

comes  necessary,  the  breech  is  well  engaged,  the  foetus  is  of  ordinary 
size,  and  the  resistance  of  the  pelvic  floor  is  inconsiderable,  the  expul- 
sion of  the  child  may  sometimes  be  effected  by  graduated  pressure 
upon  the  fundus  of  the  uterus.  Should  this  measure  prove  ineffective, 
manual  extraction  should  be  attempted.  To  this  end  the  index-finger 
should  be  inserted  into  the  fold  of  the  anterior  groin  and  traction  made 
directly  downward.  By  seizing  th3  wrist  with  the  disengaged  hand,  an 
increase  of  traction-power  can  be  exerted.  If  the  breech  is  low,  both 
index-fingers  may  be  employed— the  one  in  the  anterior,  the  other  in  the 
posterior  groin ;  or  the  entire  hand,  passed  over  the  sacrum,  may  seize 
the  pelvis  with  the  thumb  in  one  groin  and  the  index-finger  in  the 

other. 

Many  writers  insist  upon  manual  extraction  to  the  exclusion  of  all 
other  methods ;  but  in  primiparous  women  they  are  liable  to  fail  at  the 
critical  moment.  Instrumental  aids  then  become  necessary.  The 
choice  consists  in  the  forceps,  the  fillet,  the  blunt  hook,  and,  when  the 
child  is  dead,  the  cephalotribe.  So  far  as  the  relative  value  is  con- 
cerned, I  would  recommend  them  in  the  order  given. 

The  chief  objection  urged  against  the  forceps  is  that,  by  its  con- 
struction, it  is  designed  to  seize  the  fetal  head.  As  a  consequence, 
when  applied  to  the  breech  to  which  its  curves  are  not  adai)ted,  it  does 
not  grasp  the  presenting  part  securely,  and  is  liable  to  slip  off  when 
tractions  are  employed,  thus  endaiigering  the  maternal  soft  parts.  If, 
with  the  view  to  prevent  slipping,  the  handles  be  compressed  firmly,  it 
has  been  argued  that  fracture  of  the  thighs  may  result,  the  circulation 
of  the  cord  may  be  accidentally  arrested,  or  fatal  injuries  may  be 
inflicted  upon  the  foetus  by  the  pressure  of  the  points  of  the  forceps 
against  the  abdominal  viscera.  Miles,*  to  obviate  these  drawbacks, 
has  devised  a  pair  of  breech  forceps,  apparently  well  designed  for  seiz- 
ing the  pelvic  extremity.  As,  however,  a  forceps  of  special  construc- 
tion is  likely  to  be  but  rarely  at  the  disposition  of  the  physician  when 
an  emergency  calls  for  action,  it  is  not  without  interest  to  know  how 
far  the  ordinary  instrument  is  available  in  practice.  Omitting  earlier 
authorities,  we  find  in  modern  times  Jacquemier  declaring  that  "  it  is 
inexact  to  state  that  the  forceps  would  crush  the  pelvic  bones,  and  in- 
evitably kill  the  foetus  by  bruising  and  lacerating  the  abdominal  vis- 
cera." Tarnier  stated,  in  his  famous  article  on  the  forceps,  published 
in  the  Dictionnaire  de  medecine  et  de  chirurgie,  1872,  that,  under 
exceptional  circumstances,  neither  Stoltz  nor  Dubois  feared  to  apply 
the  forceps  to  the  breech,  and  added  that  he  had  a  number  of  times 
imitated  their  practice  with  success  for  the  mother,  and  sometimes  for 
the  child.  When  the  foetus  was  dead,  he  assured  himself  at  the  autopsy 
that  the  forceps  had  produced  no  lesion  either  of  the  pelvis  or  of 

*  Miles,  The  Forceps  in  Difficult  Breech  Presentations,  Am.  Jour.  Obst.,  vol. 
xii,  p.  135,  New  York,  1879. 


EXTRACTION   IN    FOOT   AND    BREECH    PRESENTATIONS.      3S9 

the  cibdo)iiinal  viscera,  lliiter,  in  his  excellent  treatise  on  Obstetri- 
cal Operations  (Leipsic,  1874),  declares  that  no  better  instrument  ex- 
ists for  the  extraction  of  the  breech.  Dr.  Henry  Fruitnight,  of  New 
York  city,  published  in  July,  1877,  in  the  Virginia  Medical  Monthly, 
a  successful  case  where  the  forceps  were  used  at  the  suggestion  of  Dr. 

E.  C.  Harwood.  Dr.  I.  E.  Taylor  has  applied  the  forceps  to  the  breech 
six  times  with  success.  In  1877  Haake*  published  five  cases  in  which, 
as  he  says,  to  the  astonishment  of  the  physicians  present,  the  extraction 
with  the  forceps  was  easily  and  quickly  ended  without  detriment  to 
the  foetus.  In  the  same  year  Agnew  reported  two  successful  cases  to 
the  London  Obstetrical  Society.     I  once  saw,  in  consultation  with  Dr. 

F.  A.  Castle,  a  case  of  breech  presentation  in  a  primipara  past  her 
thirtieth  year,  where,  after  ineffectual  essays  at  manual  extraction,  I 
applied  the  forceps  over  the  sacrum  and  the  anterior  surface  of   the 


Fig.  162.— Tarnier  forceps  applied  to  the  thighs.    (Ollivier.) 


thigh.  Though  the  breech  had  not  completed  its  descent  through  the 
cervical  canal,  and  the  parts  were  rigid,  the  child  was  easily  extracted 
in  about  fifteen  minutes.  The  child  was  alive,  and  the  trifling  press- 
ure-marks disappeared  in  a  few  days.  Recently  I  have  had  occasion 
to  apply  the  forceps  to  the  breech  in  the  case  of  an  elderly  primipara, 
where  the  rigidity  of  the  soft  parts  was  extreme.  The  operation  occu- 
pied nearly  an  hour.     The  patient  suffered  no  inconvenience,  and  only 

*  Haake,  Ueber  den  Gebrauch  der  Kopf zange  zur  Extraction  des  Steisses,  Arch. 
t  Gynaek.,  vol.  xi,  p.  558,  Berlin,  1877. 


390 


OBSTETRIC   SURGP^KV. 


a  slight  abrasion  was  found  npon  the  thigh  of  tho  chihl  which  was 
born  living.  Dr.  Harvey,  Professor  of  Midwifery  m  the  Medical  Col- 
lege of  Bengal,  in  an  essay  (1884),  reports  six  cases.  In  three  out  ot 
six  the  success  was  complete,  in  one  the  forceps  was  without  avail, 
while  in  the  other  two,  although  the  instrument  slipped,  it  did  not  do 
so  until  it  had  brought  down  the  breech,  so  as  to  allow  him  m  one  case 
to  get  his  fingers  over  the  groin,  and  in  the  other  to  apply  the  fillet, 
wliich  he  had  previously  failed  to  do. 

Since  the  invention  of  axis  traction  by  Tarnier  a  new  impetus  lias 
been  given  to  the  method.  With  axis  traction,  not  only  is  the  resist- 
ance offered  by  the  parturient  canal  diminished,  but,  as  Pmard  states, 
the  pressure  is  regulated,  and  is  not  increased  by  traction.     The  fetal 


Fig.  ](i3.— The  fillet  in  dorso-anterior  positiou.    (Ollivier.) 

part  is  seized  solidly,  and  with  the  least  risk  of  harm.  Ollivier  reports 
successes  with  Tarnier's  latest  model  in  his  own  practice,  and  in  that 
of  Budin,  Thomas,  Berthout,  Lobat,  and  Cayla. 

Thus  it  will  be  seen  that  the  weight  of  expei'ience  is  favorable  to 
the  forceps  as  a  breech -tractor,  while  the  objections  are  mainly  theo- 
retical. The  instrument  is  inadmissible  so  long  as  the  breech  does  not 
engage  in  the  pelvic  cavity.  Haake  limited  its  use  to  cases  in  whicli 
the  breech  was  already  at  the  pelvic  outlet,  and  only  after  complete 
rotation  had  taken  place.  With  axis-traction  forceps  the  indication  is 
certainly  extended,  as  a  rule,  to  all  cases  where  the  breech  has  passed 
the  pelvic  brim  and  the  dilatation  of  the  os  is  well  advanced.  If  rota- 
tion has  taken  place,  the  blades  should  be  applied,  respectively,  over  the 


EXTRACTION   IN   FOOT  AND   BREECH   PRESENTATIONS.      391 


sacrum  unci  over  the  posterior  surface  of  the  thigh,  as  recommended  by 
Haake.  If  the  hips  are  transverse,  Ollivier  advises  that  the  blades  be 
applied  to  the  lateral  surfaces  of  the  thighs.  The  application  of  the 
blades  over  the  trochanters,  with  the  extremities  overlapping  the  crests 
of  the  ilia,  is  to  be  deprecated,  as  the  ilia  are  conijiressible  and  allow 
the  forceps  to  slip  (Ollivier).  The  extraction  of  the  child  should  not 
be  made  an  exhibition  of  strength.  The  rigidity  of  the  maternal 
structures  is  rarely  to  be  overcome  by  any  justifiable  degree  of  force. 
The  slow  descent  of  the  breech,  effected  by  intermittent  traction,  best 
insures  the  physiological  softening  of  the  tissues  in  advance  of  the  pre- 
senting part.     As  the  genital  canal  softens  and  relaxes,  but  little  force 


Fio.  164.— The  fillet  in  dorso-posterior  position.     (Ollivier.) 

is  required  to  effect  the  birth  of  the  breech.  The  tractions  are  most 
effective  if  made  during  the  pains.  They  should  be  aided  by  simul- 
taneous pressure  exerted  by  an  assistant  upon  the  fundus  of  the 
uterus. 

If  the  forceps  fails,  or,  owing  to  the  non-engagement  of  the  breech, 
is  contra-indicated  and  an  extremity  can  not  be  brought  down  without 
the  employment  of  force,  a  resort  to  the  fillet  is  admissible.  The  ob- 
jections urged  to  its  use  are  :  1.  That  the  fillet  is  apt  to  become  twisted, 
and  that,  when  moistened  with  the  vaginal  secretions,  it  may  form  an 
uneven  band,  which,  even  with  care,  is  capable  of  cutting  deeply  into 
the  tissues ;  2.  That  in  some  cases  it  causes  partial  extension  of  the 
extremity,  and,  as  a  consequence,  slips  forward  upon  the  thigh,  whence 


392  OBSTETRIC  SURGERY. 

fracture  of  the  thigh-bone  becomes  inevitable.  The  reports  from  tlie 
Lying-in  Institution  of  Munich,  where,  owing  to  the  advocacy  of 
Hecker,  the  fillet  has  been  assiduously  tested,  do  not  confirm  the  idea 
that  these  accidents  are  of  necessary  occurrence.  Thus,  in  the  last  re- 
port of  Von  Weckberger  Sternefeld,  the  records  of  thirty  cases — twenty- 
one  primiparae  and  nine  pluriparae — are  given.  The  mothers  all  did 
well.  One  of  the  children  was  in  a  macerated  condition  when  the  fillet 
was  employed.  Of  the  remaining  thirty,  twenty-four  were  born  living. 
Of  these,  eight  were  partially  asphyxiated,  but  seven  were  revived.  In 
no  one  of  the  children  born  dead  was  the  result  attributable  to  the 
method  of  extraction  employed.  Twenty-three  of  the  children  left  the 
institution  in  a  healthy  condition.  In  four  cases,  deep  pressure-marks, 
but  without  excoriation,  resulted  from  the  use  of  the  fillet.  In  the 
others,  either  no  traces  of  pressure  were  found  or  they  were  of  an  in- 
significant nature.  In  all,  the  marks  had  disappeared  in  a  few  days. 
In  one  instance  only  fracture  of  the  thigh  occurred.  The  back  was 
turned  to  the  right  and  to  the  rear.  Ollivier  has  shown  that  it  is  in 
dorso-posterior  positions  that  especial  caution  is  called  for  when  trac- 
tion is  made  at  the  groin.  A  glance  at  Fig.  164  will  show  that  it  is 
not  easy  in  these  cases  to  direct  the  tractions  in  such  a  way  as  to  avoid 
the  partial  extension  of  the  thigh  and  the  transfer  of  the  pressure  to 
the  shaft  of  the  thigh-bone.  This  extension,  Ollivier  suggests,  can  be 
prevented  by  passing  the  fingers  into  the  rectum  and  pressing  the 
breech  forAvard  as  tractions  are  made.  The  fillet  should  be  jaassed 
over  the  anterior  thigh,  the  tractions  should  be  of  moderate  force, 
they  should  be  made  during  the  pains,  and  should  be  sustained  by 
external  pressure  made  by  a  skilled  assistant. 

The  passage  of  the  fillet  around  the  groin  by  the  finger  alone  is  by  no  means 
always  easy  in  the  class  of  cases  in  which  the  fillet  is  principally  indicated,  viz., 
in  those  where  the  breech  is  high  and  difficult  of  access.  To  be  sure,  with  pa- 
tience the  knotted  end  of  a  handkerchief  can  sometimes  be  pushed  around  the 
groin,  or,  failing  in  this,  an  elastic  catheter  with  a  loop  attached  to  the  ex- 
tremity may  be  guided  by  a  finger  in  the  groin  down  between  the  thighs,  to 
serve  as  a  means  of  conducting  the  fillet  into  position. 

Many  ingenious  instruments  have  been  especially  devised  to  serve  as  porte- 
fillets.  Of  these,  Ollivier's  instruments,  modified  by  him  from  an  invention  of 
Tarnier,  will  serve  as  an  example.  It  consists  of  a  long-handled  blunt  hook, 
with  a  central  tunnel  and  a  terminal  olive-shaped  bulb.  Through  the  central 
canal  a  long  piece  of  whalebone  is  passed.  The  extremity  of  the  whalebone 
terminates  in  a  metallic  eye,  which  occupies,  when  the  whalebone  is  withdrawn, 
a  hollow  space  in  the  olive-shaped  extremity  of  the  blunt  hook.  Below  the 
handle  the  end  of  the  whalebone  is  armed  with  a  button,  to  prevent  it  from 
being  accidentally  withdrawn  into  the  canal.  A  screw  above  the  handle  serves 
to  fix  the  bone  at  any  point  deemed  desirable.  The  blunt  hook  is  adjusted  by 
passing  it  upward  along  the  side  of  the  child,  directed  to  the  front  to  a  point 
above  the  pelvis,  and  then  directing  the  curve  so  as  to  adjust  it  to  the  groin. 
The  whalebone  is  then  easily  pushed  forward  until  it  is  felt  by  the  fingers  of 


EXTRACTION   IX   FOOT   AND   BREECH  PRESENTATIONS.      393 

the  physician  between  the  thighs  of  the  foetus.  The  metallic  eye  is  next  di- 
rected by  the  fingers  outside  of  the  vulva.  The  attached  fillet  is  easily  with- 
drawn by  reversing  the  directions  given. 

The  fillet  employed  may  be  of  any  material.     In  emergencies  the  nearest 
object  can  be  made  to  serve.     It  is  desirable  that  the  fillet  should  be  adjusted 


GrWtlAkUUBttO. 


Fig.  10.5.— Porte-flllet.    (.OUivier.) 

without  forming  folds  or  creases.  OUivier  recommends  passing  a  lacing  through 
a  piece  of  rubber  tubing  the  size  of  the  little  finger.  The  lacing  should  be 
fixed  by  stitches  to  the  ends  of  the  tul)e,  a  i^rojecting  portion  serving  to  attach 
the  tube  to  the  eye  at  the  end  of  the  whalebone.  In  Ollivier's  experiments  the 
^^^--JJibber  tubing  acted  admirably  in  protecting  the  tissues  of  the  child  from  harm- 
ful pressure. 

In  the  absence  of  other  appliances,  or  should  failure  attend  the 
measures  already  described,  it  is  well  to  remember  that  the  blunt  hook 
owes  its  sinister  reputation  not  so  much  to  its  inherent  defects  as  to 
lack  of  proper  caution  in  its  employment.  It  will  not  break  the  femur 
if  adjusted  in  the  groin.  It  will  not  produce  serious  contusions  if 
the  blunt  end  is  carefully  guarded  by  the  finger.  Injuries  to  the 
maternal  tissues  can  only  occur  where  leverage  movements  are  made. 
So  long  as  the  pressure  of  the  curved  portion  is  confined  to  the  groin, 
serious  lesions  are  not  likely  to  be  produced.  Steady  downward  trac- 
tions, made  with  moderate  force  and  with  a  hand  in  the  vagina  to 
guard  the  point  of  the  instrument,  and  to  give  warning  of  commenc- 
ing extension  of  the  thigh,  will  in  the  rule  suffice  to  prevent  serious 
accidents. 

No  instrument  is  capable  of  seizing  the  breech  so  securely  as  the 
cephalotribe.  If,  therefore,  the  child  be  dead — a  fact  rarely  to  be  de- 
termined except  in  cases  where  the  cord  can  be  reached — the  cephalo- 
tribe, screwed  tightly  to  the  breech,  can  be  trusted  to  act  as  a  reliable 
tractor. 

Management  of  the  Cord. — So  soon  as  the  cord  has  passed  beyond 
the  vulva,  dragging  upon  the  navel  should  be  avoided  by  genth'  jjull- 
ing  the  cord  downward  into  one  of  the  recesses  to  the  sides  of  the 
promontory  until  some  resistance  is  experienced.  Sometimes  the  cord 
is  found  passing  between  the  child's  legs  and  up  over  its  back  to  the 
placenta.  Then  traction  should  be  exerted  upon  the  placental  ex- 
tremity, and  an  attempt  made  to  slip  the  loop  over  the  posterior  thigh. 
In  the  rare  cases  of  failure  to  obtain  its  release,  and  where  the  cord  is 
wound  around  the  child's  body,  either  two  ligatures  or  compression 


394  OBSTETRIC  SURGERY, 

forceps  should  be  applied,  aud  the  cord  be  divided  between  them, 
whereupon  every  effort  should  be  put  forth  to  complete  the  delivery  as 
speedily  as  possible. 

Seco^td  Act:  Liberation^  of  the  Aems. 

When  the  Arms  are  flexed  upon  the  Thorax.— After  providing  for 
the  safety  of  the  cord,  the  pelvis  of  the  child  should  be  seized  m  the 
two  hands  with  the  thumbs  upon  the  sacrum.  Traction  should  be 
employed  in  a  downward  direction  until  the  shoulder-blades  make 
their  appearance.  Then  no  time  should  be  lost  in  liberating  the  arms. 
If  the  latter  are  folded  upon  the  chest,  delivery  is  an  easy  matter.  The 
palmar  surface  of  the  corresponding  hand  is  passed  over  the  belly  of  the 
child  to  the  posterior  arm  (back  to  the  right,  right  hand,  and  vice  ver- 
sa), while  the  extremities,  wrapped  in  a  warm  cloth,  are  drawn  in  the 
opposite  direction.  The  forearm  should  be  seized  as  near  the  wrist  as 
possible,  and  be  brought  down  over  the  abdomen  to  the  side  of  the 
child. 

When  the  Arms  are  extended.— Unless,  however,  great  care  has 
been  exerted  during  extraction  to  keep  the  uterus  by  external  pressure 
closely  in  contact  with  the  foetus,  the  friction  of  the  parturient  canal  is 
apt  to  brush  one  or  both  arms  upward  to  the  sides  of  the  child's  head. 
In  such  cases  the  difficulties  involved  in  liberating  the  arms  are  often 
very  great.  Here,  too,  owing  to  the  increased  amount  of  space  afforded 
by  the  curvature  of  the  sacrum,  an  attempt  should  first  be  made  to  re- 
lease the  posterior  arm. 

Release  of  the  Posterior  Arm. — This  is  best  accomplished  by  draw- 
ing the  lower  extremities  strongly  upward  and  to  the  side,  thereby 
causing  the  posterior  shoulder  to  sink  deeper  in  the  pelvis  and  to 
furnish  more  room  for  the  introduction  of  the  hand ;  then  two  fingers 
should  be  passed  along  the  side  of  the  child  to  the  elbow-joint,  which 
should  be  pushed  across  the  face,  and  be  brought  down  over  the 
thorax. 

In  case  the  foregoing  manoeuvre  can  not  be  rapidly  executed, 
the  operating  hand  may  be  removed,  and  the  extremities  of  the  child 
may  be  drawn  in  the  opposite  direction,  while  the  hand  which  at  first 
had  seized  the  feet  or  breech  should  pass  upward  over  the  abdominal 
surface  to  the  posterior  elbow.  The  latter  should  then  be  directed 
forward,  by  means  of  two  fingers  in  the  Joint,  toward  the  anterior 
pelvic  wall. 

Whether  the  hand  be  passed  behind  or  in  front  of  the  child,  it 
should  be  introduced  slowly  and  without  force  during  the  intermis- 
sion between  the  pains.  Pressure  should  always  be  made  at  the  joint, 
and  never  upon  the  humerus.  A  forgetfulness  of  the  latter  rule  is 
apt  to  produce  fracture. 

Release  of  the  Anterior  Arm. — As  there  is  rarely  space  enough  be- 


EXTRACTION  IN  FOOT  AND  BREECH  PRESENTATIONS.   395 

tweeu  the  sym})hysis  aud  the  shoulder  to  allow  the  iingerrf  to  rqach  the 
elbow,  it  is  customary  after  release  of  the  posterior  arm  to  rotate  the 
trunk  so  as  to  bring  the  anterior  arm  backward  into  the  cavity  of  the 
sacrum.  This  is  accomplished  with  the  least  disturbance  of  the  nor- 
mal mechanism  by  seizing  the  released  arm  and  drawing  it  upward  on 
the  dorsal  side  of  the  child.  The  shoulders  readily  follow  the  move- 
ment until  the  half-circle  rotation  is  completed. 

Exceptional  Cases. — The  shoulders,  in  place  of  rotating  into  the 
conjugate  diameter,  may  enter  transversely  into  the  pelvis.  If  the 
back  then  be  turned  toward  the  symphysis,  the  hand  should  be  passed 
over  the  abdominal  surface  in  search  of  the  arms.  The  space  oppo- 
site the  sacrum  renders  this  movement  one  of  easy  execution.  When 
the  back  is  turned  to  the  rear,  so  long  as  the  arms  are  flexed,  the  hand 
should  search  for  them  under  the  symphysis  pubis.  If,  however,  they 
are  extended  upon  the  sides  of  the  child's  head,  it  is  rarely  possible  to 
push  the  arms  forward  between  the  face  and  the  symphysis  pubis. 
An  effort  should  be  made,  therefore,  to  bring  one  arm  to  the  rear  by 
rotating  the  thorax  with  the  hands.  Michaelis  succeeded  twice  in 
similar  cases  without  rotating  the  trunk,  by  passing  the  hand  behind 
the  dorsal  surface  of  the  child  and  drawing  the  elbow  backward  and 
downward  below  the  side-wall  of  the  pelvis,  and  then  pushing  the 
forearm  over  the  thorax.*  I  have  repeatedly  tested  this  movement  in 
passing  the  cadaver  of  an  infant  through  a  bony  pelvis,  and  find  that 
it  can  be  accomplished  without  producing  fracture  or  dislocation.  Of 
course,  during  the  life  of  the  child  the  result  may  be  different. 

Sometimes,  in  rotating  the  shoulders,  the  anterior  arm  becomes 
displaced  backward,  so  that  the  forearm  is  thrown  across  the  neck  of 
the  child.  When  this  accident  is  of  recent  occurrence,  the  release  of 
the  arm  may  be  accomplished  by  pressing  the  thorax  of  the  child  back- 
ward into  the  genital  passage,  and  rotating  the  body  in  the  reverse 
direction  from  that  which  produced  the  difficulty.  If,  however,  trac- 
tions have  been  made  upon  the  child  until  the  head  has  entered  the 
pelvis,  the  arm  may  become  so  compressed  between  the  neck  and  the 
symph3^sis  pubis  as  to  render  its  liberation  a  very  difficult  if  not  im- 
possible task.  Then  every  resource  should  be  quickly  tested  to  turn 
the  shoulder  of  the  displaced  arm  to  the  rear,  either  by  raising  the  re- 
leased arm,  or  by  rotating  the  thorax,  or  by  drawing  upon  the  elbow. 
In  case  of  failure  to  obtain  a  speedy  result,  extraction  may  be  at- 
tempted without  releasing  the  arm.  To  be  sure,  fracture  of  the 
humerus  is  thereby  rendered  highly  probable ;  but  if  the  bystanders 
are  forewarned  that  the  risk  is  incurred  in  the  interest  of  the  child, 
they  are  generally  ready,  where  the  life  of  the  latter  is  preserved,  to 
condone  the  injury. 

In  setting  a  fractured  arm,  soft  jiads  should  be  baiulaged  upon  the 
*  Michaelis,  Abhandlungen.  Kiel.  1833.  p.  230. 


3,j(3  OBSTETRIC   SURGERY. 

auterior  and  posterior  surface  to  hold  the  extremities  in  position.  The 
posterior  pad  should  run  the  entire  length  of  the  arm ;  the  anterior 
pad  need  not  extend  below  the  elbow.  The  arm  should  then  be  band- 
aged to  the  thorax.  In  two  or  three  weeks  consolidation  takes  place.* 
In  performing  artificial  rotation,  it  is  well  to  bear  the  warning  of 
Dr.  Barnes  in  mind,  viz.,  "  That  the  atlas  forms  with  the  axis  a  rota- 
tory Joint,  so  constructed  that,  if  the  movement  of  rotation  of  the  head 
be  carried  beyond  a  quarter  of  a  circle,  the  articulating  surfaces  part 
immediately,  and  the  spinal  cord  is  compressed  or  torn.^f  Pains 
should  accordingly  be  taken  to  note,  when  a  half-turn  is  given  to  the 
body,  whether  the  head  follows  the  movements  of  the  trunk. 

Third  Act:   Extraction  of  the  Head. 

In  the  extraction  of  the  head  we  have  to  distinguish— 1.  Cases  in 
which  the  head  has  entered  the  pelvis,  and  has  only  to  overcome  the 
resistance  of  the  perineum  ;  2.  Cases  where  the  head  is  retained  at 
the  brim  by  pelvic  contraction,  stricture  of  the  os  uteri,  extension  of 
the  chin,  or  insufficient  expulsive  action  exerted  by  the  uterus  and  the 
abdominal  muscles. 

1.  Extraction  of  the  Head  after  it  has  entered  the  Pelvis.  Smellie's 
Method. — In  the  so-called  Smellie's  method  the  trunk  of  the  child  is 
wrapped  in  a  warm  napkin  and  placed  astride  the  operator's  arm ;  the 
hand  is  then  passed  into  the  vagina,  and  the  index  and  middle  fingers 
are  placed  upon  the  fossaj  caninae  to  the  sides  of  the  child's  nose.  At 
the  same  time,  upward  pressure  is  made  with  the  fingers  of  the  other 
hand  upon  the  occiput.  By  this  means  flexion  of  the  head  is  induced. 
Then  by  raising  the  trunk  the  face  is  rolled  out  over  the  perina3um. 
This  method  possesses  the  advantage  of  avoiding  the  risks  of  injuring 
the  child  which  are  incident  to  the  other  procedures.  It  requires  for 
its  successful  performance  the  completion  of  rotation,  a  small  head, 
and  a  lax  perin^eum. 

Combined  Traction  upon  the  Chin  and  Shoulders. — In  case  the  fore- 
going plan  is  not  followed  by  immediate  success,  the  two  fingers  upon 
the  fossae  caninae  should  be  introduced  into  the  mouth,  and  the  index  and 
middle  fingers  of  the  other  hand  should  be  forked  upon  the  shoulders. 
Tractions  should  be  made  somewhat  downward,  until  the  neck  has  been 
drawn  below  the  pubic  arch  and  the  chin  has  reached  the  coccyx. 
Then,  with  occiput  resting  against  the  pubic  walls,  by  a  deliberate  joint 
movement  of  the  two  arms  the  body  should  be  raised,  and  the  face  and 
brow  be  made  to  rotate  over  the  coccyx  and  perinaeum.  By  this  method 
there  is  obtained  the  greatest  amount  of  traction  force  in  combination 
with  the  least  degree  of  violence  to  the  child.  As  the  power  is  exerted 
chiefly  upon  the  shoulders,  the  fingers  in  the  mouth  are  not  likely  to 

*  Spiegelberg,  Lehrbuch,  etc.,  p.  809. 

f  Barnes,  Obst.  Operations,  Am.  ed.,  p.  210. 


EXTRACTION   IN   FOOT   AND   BREECR   PRESENTATIONS.      397 

fracture  the  jaw,  but  by  keeping  the  chin  flexed  and  drawing  gently 
uto-  it,  the  danger  of  twisting  the  neck,  in  cases  where  the  rotaUon  of 
the  face  into  the  hollow  of  the  sacrum  is  incomplete,  is  avoided. 


Fig.  166.-Combmed  traction  upon  mouth  and  shoulders.    (Faraboeuf  and  Varnier.) 


When  the  occiput  is  turned  into  the  hollow  of  the  sacrum  and  the 
iorehead  is  pressed  against  the  symphysis  the  process  ^^^fl^f^^ 
should  be  reversed.  As  the  fingers  are  forked  over  the  shoulders,  the 
back  of  the  child  should  rest  upon  the  arm.     With  one  or  two  fingeis 

.  The  combined  traction  upon  the  chin  and  shoulders  is  in  Ge^a^y  f  own  a 
the  Smeiiie-Veit  modified  method,  the  latter  having  warmly  advocated  the  measure 
In  ISeT    In  a  historical  discussion  of  the  subject  Litzmann  shows  that,  as  regards 
priority  of  description,  the  credit  properly  belongs  to  Maunceau. 


398 


OBSTETRIC  SURGERY. 


of  the  other  hand  the  ehiu  should  be  flexed.  Tractions  should  be  made 
downward,  so  that  while  the  neck  rests  upon  the  perineum  the  fore- 
head rotates  under  the  symphysis  pubis. 

Ordinarily,  when  the  head  enters  the  pelvis  in  a  transverse  direc- 
tion, the  occiput  rotates  to  the  symphysis  pubis  during  extraction. 
Should  the  head,  however,  remain  with  its  long  diameter  in  the  trans- 
verse diameter  of  the  pelvis,  a  hand  introduced  into  the  vagina,  with 
the  back  to  the  sacrum  and  the  fingers  over  the  chikFs  face,  may 

sometimes  be  successfully  employed  to 
rotate  the  latter  into  the  sacral  con- 
cavity. 

•2.  Extraction  with  the  Head  at  the 
Brim. — W'itli  the  head  at  the  brim,  the 
combined  method  as  given  above  is 
available  in  all  ordinary  emergencies. 
As,  however,  the  life  of  the  child  de- 
pends upon  the  speedy  extraction  of 
the  head,  it  is  well  to  become  familiar 
with  the  various  procedures,  as,  by  pass- 
ing rapidly  from  one  to  another,  a  suc- 
cessful result  is  often  obtained,  when 
failure  might  have  followed  ineffectual 
efforts  in  a  single  direction. 

The  Prague  Method  owes  its  mod- 
ern name  to  tbe  advocacy  of  Kiwisch, 
►Scanzoni,  and  Lange,  all  representatives 
of  the  Prague  school.  It  was,  however, 
nearly  a  century  earlier  described  by 
Pugh.  It  consists  in  seizing  the  feet 
with  one  hand,  and  directing  the  body 
of  the  child  nearly  vertically  downward. 
The  fingers  of  the  other  hand  are  hooked 
over  the  shoulders  of  the  child,  so  that 
the  tips  rest  upon  the  supra-clavicular 
region.  Traction  is  exerted  by  both 
hands  simultaneously.  In  the  absence 
of  pains,  external  pressure  upon  the  head 
should  be  made  by  an  assistant  through 
the  abdominal  walls.  Care  should  be 
taken  to  avoid  twisting  the  neck,  and  to  preserve  the  normal  relations 
between  the  head  and  the  shoulders.  After  the  head  has  passed  the 
brim  and  fairly  entered  the  pelvis,  the  hand  upon  the  neck  is  em- 
ployed as  a  fulcrum,  while  the  extremities  are  raised  rapidly  toward 
the  abdomen  of  the  mother ;  the  friction  from  the  inner  surface  of 
the  symphysis  pushes  the  occiput  upward,  and  forces  the  face  to  de- 


FiG.  167.— Extraction  by  the  Prague 
method. 


EXTRACTION   IN   FOOT  AND   BREECH   PRESENTATIONS.     399 

Bcend   into    the   hollow  of   the  sacrum  and  to  sweep  over  the  peri- 
nseum. 

When  the  chin  is  directed  to  the  front,  and  at  the  same  time  is 
arrested  at  the  symphysis  pubis,  if  the  occiput  occupies  the  hollow  of 


Fig.  168.— The  Prague  method  of  extracting  head. 

the  sacrum,  the  body  of  the  child  should,  during  the  tractions,  be 
directed  toward  the  abdomen  of  the  mother,  so  as  to  cause  the  occiput 
to  rotate  over  the  perineum. 

The  so-called  Prague  method  is  particularly  serviceable  in  cases  of 
flattened  pelvis,  in  which  the  chin  normally  is  partially  extended  as  the 
head  engages  in  the  sagittal  diameter  of  the  brim. 

Forceps  to  the  After-coming  Head. — The  forceps  to  the  after-com- 
ing head  has  been  condemned  by  some  and  warmly  approved  by  others. 
As,  however,  with  its  aid  I  have  in  a  number  of  instances  extracted 
children  alive  in  cases  where  the  foregoing  methods  have  failed  me,  it 
is  now  my  custom  to  have  the  blades  duly  warmed  and  ready  to  hand 
before  attempting  manual  extraction.  The  instrument  is  occasionally 
of  use  in  overcoming  the  resistance  of  a  rigid  perinseum  in  strongly 
built  primiparae,  but  is  chiefly  indicated  when  both  occiput  and  chin 
are  arrested  at  the  superior  strait.  With  the  chin  anterior,  the  forceps 
should  be  applied  under  the  back  of  the  child,  and  the  handles  raised 
so  as  to  bring  the  occiput  into  the  hollow  of  the  sacrum.     With  the 


400 


OBSTETRIC   SURGERY. 


chin  to  the  rear,  the  forceps  should  be  applied  uuder  the  abdomen,  and 
be  used  to  draw  the  face  into  the  sacrum.  Where  the  arrest  of  the 
head  is  due  to  stricture  of  the  os  externum  or  internum,  the  forceps 
will  sometimes  bring  the  head  rapidly  through  the  cervix,  when  trac- 
tion upon  the  feet  only  serves  to  drag  the  uterus  to  the  vulva.  In 
stricture  of  the  cervix,  however,  great  care  must  be  exercised  to  avoid 
laceration,  as  uuder  no  circumstances  are  extensive  ruptures  of  the 
lower  uterine  segment  so  apt  to  follow  as  in  the  forcible  extraction  of 
the   after-coming   head.      Should   this   happen,   the   writer   urgently 


Fig.  169.— Chin  arrested  at  symphysis.    (ChaiIly-Honor6.) 

counsels  the  immediate  employment  of  the  suture,  as  the  dangers  of 
childbed  are  thereby  diminished,  and  much  immediate  and  prospect- 
ive suffering  are  prevented.  Tlie  introduction  of  a  large-sized  catheter 
into  the  child's  mouth  and  drawing  back  the  perinaeum  have  been 
found  useful  as  temporary  means  of  introducing  air  into  the  child's 
lungs,  where  delay  attends  efforts  at  delivery. 

In  extracting  the  after-coming  head,  the  axis-traction  forceps  is 
particularly  serviceable. 


CHAPTER   XXI. 

VERSION. 

Cephalic  version. — External  method. — Combined  method. 
Wright.— Hohl. — Braxton  Hicks. — Podalic  version.- 
nal  version.— Neglected  version.— Use  of  the  fillet. 

Version,  or  turning,  is  the  term  emiDloyed  for  the  operations  by 
means  of  which  an  artificial  change  is  effected  in  the  presentation  of 
the  child.     It  comprises  the  substitution  of  one  pole  of  the  foetus  for 


-Busch. — D'Outrepont. — 
-Bipolar  method. — Inter- 


VERSION.  401 

the  other,  and  the  conversion  of  an  oblique  or  shoulder  presentation 
into  one  in  which  the  long  axis  of  the  fu3tus  corresponds  to  the  verti- 
cal axis  of  the  uterus. 

It  is  customary  to  designate  specifically  the  character  of  the  version 
by  mentioning — 1.  The  presentation  to  be  changed.  Thus,  versioii  is 
made  from  the  head,  the  breech,  or  the  shoulder,  as  the  presenting 
part.  2.  The  presentation  to  be  effected.  The  term  cephalic  version 
is  used  where  the  head  is  brought  to  the  brim  of  the  pelvis,  and  po- 
dalic  version  where  the  feet  are  seized  and  the  extremities  made  the 
presenting  part.  3.  The  method  adopted  by  which  version  is  accom- 
plished. The  expression  external  version  is  applied  to  manipulations 
exclusively  through  the  abdominal  walls  ;  internal  version,  to  the  in- 
troduction of  the  entire  hand  into  the  uterus ;  and  the  combined 
method  to  cases  in  which  both  hands,  the  one  externally  and  the  other 
with  two  to  four  fingers  introduced  through  the  os,  co-operate  together. 

Cephalic  Version. — When  it  is  simply  required  to  rectify  a  faulty 
presentation  (shoulder  or  transverse),  without  reference  to  modifying 
circumstances,  cephalic  version  unquestionably  deserves  the  preference. 
In  practiee,  however,  this  method  requires  the  concurrence  of  so  many 
favorable  conditions  that  its  employment  is  very  limited.  For  instance, 
there  must  be  no  comjjlications  which  call  for  rapid  delivery.  It  would 
be  unsuitable  in  prolapse  of  the  cord  and  in  cases  of  placenta  previa. 
There  should  be  nothing  to  prevent  the  child's  head  from  entering  the 
brim  of  the  pelvis.  It  should,  therefore,  not  be  attempted  in  con- 
tracted pelves.  A  prolapsed  arm,  unless  previously  replaced,  would 
render  the  operation  impossible.  The  child  should  enjoy  a  considera- 
ble degree  of  mobility.  An  abundance  of  amniotic  fluid  contributes 
much,  though  it  is  not  indispensable,  to  success,  as,  even  after  the 
rupture  of  the  membranes,  provided  the  uterine  walls  are  sufficiently 
relaxed,  the  head  may  be  brought  into  the  pelvis.  Before  rupture, 
excessive  sensitiveness  to  manipulations,  and,  after  rupture,  rigidity  of 
the  uterus,  stand  in  the  way  of  success. 

The  operation  may  be  performed  by  either  the  external  or  the  com- 
bined method. 

Of  the  external  methods  the  best  is  that  which  is  known  as  AVi- 
gand's  (1807),  which  combines  a  suitable  position  of  the  mother  with 
manipulations  through  the  abdominal  walls.  The  mother  is  at  first 
made  to  lie  upon  her  back,  with  knees  fiexed,  and  with  the  abdomen 
exposed  or  covered  by  some  light  material.  The  j^hysician  stands  by 
the  side  of  the  patient,  looking  in  the  direction  of  her  face.  He  be- 
gins by  laying  his  hands  flat  upon  the  surface  of  the  abdomen,  and 
seeks  with  the  one  the  head  and  with  the  other  the  breech  of  the  fostus. 
During  the  intervals  of  the  pains,  by  gentle  movements  of  the  two 
hands  working  simultaneously,  he  strives  to  press  up  the  breech  and 
anterior  surface  of  the  child  and  to  bring  the  head  into  the  peb  ic 
26 


402  OBSTETRIC  SURGERY. 

brim.  Should  the  uterus  harden,  all  friction  movements  of  the  hands 
should  cease,  and  the  efforts  of  the  operator  be  confined  to  holding  the 
foetus  steady  in  the  position  previously  produced.  The  movement  may 
be  aided  by  turning  the  woman  upon  the  side  toward  which  the  head 
is  directed.  As  the  fundus  of  the  uterus  sinks  to  the  side  upon  which 
the  woman  lies,  it  carries  the  breech  of  the  child  with  it,  while  the 
change  in  the  uterine  axis  tends  to  throw  the  cephalic  end  in  the  op- 
posite direction. 

When  the  head  is  once  brought  to  the  brim  of  the  pelvis  it  may  be 
retained  in  situ,  if  the  patient  lies  upon  her  side,  by  the  hand  of  an 
assistant,  or  by  a  small,  hard  pillow  pressed  firmly  against  it.  If  the 
patient  lies  ujDon  the  back,  two  compresses  may  be  laid  along  the  sides 
of  the  uterus  near  the  head,  and  a  bandage  ajoplied  to  the  abdomen  to 
keep  them  in  i^osition.  When  the  pains  are  regular  and  the  cervix 
partially  dilated,  fixation  of  the  head  may  be  accomplished  by  ruptur- 
ing the  membranes  and  allowing  the  waters  to  escape.  Until  the 
uterus  retracts  down  upon  the  child,  the  head  should  be  held  at  the 
brim  either  by  the  two  hands  through  the  abdominal  walls,  or  by  the 
thumb  and  four  fingers  of  one  lyind  applied  directly  to  jthe  head 
through  the  cervix. 

The  more  important  of  the  combined  methods  are  those  of  Busch, 
D'Outrepont,  Wright,  Hohl,  and  Braxton  Hicks.     They  have  in  com- 


FiG.  irC— D'Outrepont's  method,  modified  by  Scanzoni. 


mon  the  simultaneous  employment  of  the  external  and  internal  hand. 
They  differ,  however,  in  detail.  The  methods  of  Busch  and  D'Outre- 
pont have  now  chiefly  an  historical  interest.  Busch  introduced  the 
hand  corresponding  to  the  child's  head  through  the  vagina  and  cervix, 
while  counter-pressure  was  made  with  t!ie  other  hand  upon  the  fundus 


VERSION.  403 

uteri.  The  back  of  the  hand  is  at  first  directed  to  the  front.  When, 
however,  its  widest  portion  has  passed  above  the  symphysis  pubis,  the 
back  of  the  hand  is  turned  to  the  concavity  of  the  sacrum,  and  the  fin- 
gers are  pushed  up  with  care  between  the  membranes  and  the  uterus  to 
the  head.  The  membranes  are  then  ruptured,  and  during  the  escape 
of  tlie  waters  the  head  is  seized  by  the  fingers  and  thumb  and  drawn 
into  the  pelvis,  while  the  disengaged  hand  presses  the  breech  toward 
the  median  line.  Every  pains  should  be  taken  to  prevent,  with  the 
fingers,  the  prolapse  of  the  cord,  or  of  an  arm,*  during  the  escape  of 
the  water.  D'Outrepont  seized  the  presenting  shoulder  between  the 
thumb  and  fingers  of  the  hand  corresponding  to  the  breech,  and, 
during  the  intervals  between  the  pains,  pushed  the  shoulder  upward 
and  in  the  direction  of  the  breech  until  the  head  descended  into  the 
pelvis.  During  this  manoeuvre  D'Outrepont  simply  used  the  external 
hand  to  support  the  uterus.  Scanzoni  recommended  that  it  should  be 
employed  externally  to  press  the  head  toward  the  pelvic  brim.f 

Wright's  method  differs  from  that  of  D'Outrepont,  in  that  he  em- 
ployed, to  seize  the  shoulder,  the  hand  corresponding  to  the  head,  and 
while  he  pushed  the  shoulder,  without  lifting,  in  the  direction  of  the 
curve  of  the  uterus,  he  applied  the  remaining  hand  to  dislodge  the 
breech,  and  move  it  toward  the  center  of  the  uterine  cavity. J 

All  the  foregoing  methods  require  for  their  successful  performance 
a  movable  foetus  and  a  dilated  cervix — conditions  which  render  podalic 
version  safe  and  of  easy  execution.  In  practice,  therefore,  they  have 
never  enjoyed  any  considerable  degree  of  popularity.  Of  far  greater 
importance  are  the  methods  of  Hohl  and  Braxton  Hicks,  which,  pos- 
sessing the  advantage  of  requiring  the  introduction  of  two  fingers  only 
into  the  uterus,  can  consequently  be  resorted  to  at  an  early  stage  of 
labor.  Hohl,  like  Wright,  employed  for  internal  use  the  hand  corre- 
sponding to  the  head.  With  two  fingers  in  the  cervix,  he  pushed  the 
top  of  the  shoulder  in  the  direction  of  the  breech,  and  pressed  the 
head  into  the  pelvis  with  the  external  hand.  At  the  same  time  he  in- 
trusted to  an  assistant  the  task  of  seizing  the  fundus  of  the  uterus  be- 
tween the  palms  of  the  hands,  and  directing  it  to  the  side  toward  which 
the  head  was  originally  turned.*  Braxton  Hicks  describes  his  method 
as  follows  :  "  Introduce  the  left  hand  into  the  vagina  as  in  podalic  ver- 
sion ;  place  the  right  hand  on  the  outside  of  the  abdomen,  in  order 
to  make  out  the  position  of  the  foetus  and  the  direction  of  the  head 
and  feet.  Should  the  shoulder,  for  instance,  present,  then  push  it, 
with  one  or  two  fingers  on  the  top,  in  the  direction  of  the  feet.  At 
the  same  time  pressure  by  the  outer  hand  should  be  exerted  upon  the 
cephalic  end  of  the  child.     This  will  bring  down  the  head  close  to  the 

*  Scanzoni,  Lehrbuch  der  Geburtshiilfe,  1867,  Bd.  iii,  p.  63.  t  Op.  cit.,  p.  65. 

X  Wright,  Am.  .Jour,  of  Obstet.,  vol.  vi,  part  1, 1873. 

«  Hohl,  Lehrbueh  der  Geburtshulfe,  2te  Auflage,  1862,  p.  784. 


^Q^  OBSTETRIC  SURGERY. 

OS ;  then  let  the  head  be  received  upon  the  tips  of  the  inside  fingers. 
The  head  will  play  like  a  ball  between  the  hands,  and  can  be  placed  m 
almost  any  part  at  will.  ...  It  is  as  well,  if  the  breech  will  not  rise 
to  the  fundus  readily  after  the  head  is  fairly  in  the  os,  to  withdraw 
the  hand  from  the  vagina  and  with  it  press  up  the  breech  from  the 
exterior."  *  Lately,  Hicks  has  proposed  to  employ  the  external  hand 
to  alternately  press  the  head  into  the  os  and  the  breech  to  the  fundus. 
His  plan  differs  from  that  of  Hohl,  in  that  he  operates  with  the  pa- 
tient upon  the  side,  and  uses  the  left  hand  with  the  patient  upon  the 
left  side,  and  the  right  hand  when  she  lies  upon  the  right.  He  like- 
wise dispenses  with  an  assistant. f 

Podalic  Version.— Podalic  version  is  indicated  in  the  following  cases  : 

1.  The  transverse  presentation,  where  cephalic  version  is  contra- 
indicated,  or  attended  with  any  considerable  degree  of  difficulty. 

2.  In  head  presentations,  where  there  is  reason  to  suppose  that  the 
result  would  be  favorably  influenced  by  bringing  down  the  feet.  As 
illustrations  of  such  conditions,  we  have  faulty  presentations  of  the 
head  and  face,  prolapse  of  the  cord  and  extremities,  placenta  prsevia, 
and  contracted  pelvis.  The  various  contingencies  which  call  for  ver- 
sion will  be  more  closely  considered  in  connection  with  the  special 
morbid  conditions  mentioned. 

The  operation  may  be  performed  by  combined  external  and  inter- 
nal manipulations,  or  by  the  internal  hand  alone. 

The  Bipolar  or  Combined  Method  of  Braxton  Hicks.— In  the  bi- 
polar method  of  turning,  the  two  hands  operate  simultaneously  upon 
the  extremities  of  the  foetus.  It  may  be  carried  out  at  will  with  the 
patient  upon  the  side  or  upon  the  back.  The  latter  position  is  the 
one  which  finds  most  favor  in  this  country.  The  patient  should  be 
placed  transversely  in  the  bed  and  the  nates  drawn  to  the  edge.  Two 
assistants  are  required  to  hold  the  legs,  which  should  be  flexed  and  ro- 
tated outward.  As  the  beds  in  America  are  very  low,  where  difficulty 
in  operating  is  anticipated  it  is  sometimes  advisable  to  remove  the 
patient  after  she  has  been  anaesthetized  to  a  table  covered  with  a  blan- 
ket or  woolen  comforter.  Complete  anaesthesia  is  useful  as  a  means 
of  facilitating  the  introduction  of  the  internal  hand,  and  maintaining 
a  relaxed  condition  of  the  uterus.  Care  should  be  taken  that  both 
bladder  and  rectum  are  emptied.  The  hand  selected  for  internal 
manipulations  should  be  of  the  same  name  as  the  side  to  which  the 
extremities  are  turned — i.  e.,  feet  to  the  right,  right  hand;  feet  to 
the  left,  left  hand. J;     The  fingers  should  be  brought  together  in  the 

*  Hicks,  Combined  External  and  Internal  Version,  Trans,  of  the  Obstet.  Soc.  of 
London,  vol.  v,  p.  230. 

t  Hicks,  Am.  Jour,  of  Obstet.,  July,  1879,  p.  593. 

X  In  England  the  patient  is  delivered  upon  the  left  side,  and  the  left  hand  is 
commonly  introduced  into  the  vagina.    In  Germany,  when  the  patient  lies  upon  the 


VERSION.  405 

form  of  a  cone.  The  back  of  the  haud  and  forearm  should  be  well 
lubricated  with  oil  or  lard.  In  passing  the  hand  into  the  vagina,  the 
labia  should  be  separated  by  the  thumb  and  fingers  of  the  disengaged 
hand.  Entrance  is  effected  by  directing  the  fingers  toward  the  sa- 
crum, and  pressing  backward  upon  the  distensible  perineum.  In  this 
stage  of  the  procedure  hasty  action  is  out  of  place.  Patience  and  gen- 
tleness are  the  prime  requisites.  Two  or  three  fingers  only  need  to  be 
carried  through  the  internal  os.  When  the  presenting  part  is  reached, 
the  external  hand  should  be  laid  upon  the  abdomen,  and  pressure 
brought  to  bear  upon  the  breech.  The  two  hands  should  then  move  the 
extremities  of  the  child  in  opposite  directions.  To  quote  Dr.  Barnes, 
"  The  movements  by  which  this  is  effected  are  a  combination  of  con- 
tinuous pressure  and  gentle  impulses  or  taps  with  the  finger-tips  on 
the  head  (or  shoulder),  and  a  series  of  half-sliding,  half-j)ushing  im- 
pulses with  the  palm  of  the  hand  outside."  When  the  breech  is  well 
pressed  down  to  the  iliac  fossa,  the  membranes  should  be  ruptured 
during  a  pain,  and  a  knee,  which  at  this  time  is  generally  near  the  os 
internum,  should  be  seized  and  hooked  into  the  vagina  with  the  fin- 
gers. As  the  breech  is  brought  into  the  pelvis  by  tractions  upon  the 
leg,  the  outer  hand  should  be  employed  to  press  up  the  head  until  the 
version  is  completed. 

The  manipulations  described  are  to  be  conducted  during  the  inter- 
vals between  the  pains.  Care  should  be  taken  not  to  hook  down  the 
cord  with  the  knee.  When  the  lower  extremities  are  reflected  upward 
upon  the  body  so  that  a  knee  is  not  attainable,  the  breech  may  often 
be  brought  down  by  a  finger  inserted  into  the  fold  of  the  thigh,  or  by 
pressure  upon  some  part  of  the  pelvis. 

The  combined  method  of  version,  which  we  owe  in  all  its  essential 
features  to  Braxton  Hicks,  is  one  of  the  most  important  contributions 
to  obstetrical  practice  of  the  present  century.  It  possesses  the  price- 
less advantages  of  enabling  the  physician  to  perform  version  early  in 
labor,  and  to  accomplish  the  operation  without  in  any  way  imperiling 
the  integrity  of  the  uterus.  The  only  prerequisites  for  success  are : 
sufficient  dilatation  of  the  cervix  to  permit  the  passage  of  two  fingers, 
a  certain  degree  of  fetal  mobility  within  the  uterine  cavity,  and  a  pre- 
cise knowledge  of  the  fetal  position.  After  rupture  of  the  membranes 
and  escape  of  the  waters,  the  operation  becomes  more  difficult,  but  is 
even  then  not  always  impracticable. 

Internal  Version. — In  internal  version  the  entire  hand  is  introduced 
into  the  uterus.  It  is  necessary,  therefore,  that  the  cervix  should  be  so 
far  dilated  that  the  hand  can  be  passed  without  violence  through  the 
cervical  canal.  Irregular  uterine  contractions  require  to  be  relieved 
by  hypodermic  injections  of  morphia,  with  or  without  the  addition  of 

right  side,  the  left  hand  is  employed  inside :  when  upon  the  left  side,  the  right  hand. 
The  choice  of  hands,  it  will  be  seen,  is  not  a  matter  of  considerable  importance. 


406 


OBSTETRIC  SURGERY. 


atropia,  or  by  the  induction  of  comiDlete  anaesthesia.  As  internal  ver- 
sion is  not  an  indifferent  operation,  but  may  be  followed  by  inflamma- 
tions due  either  to  injuries  of  the  maternal  tissues  or  to  the  introduc- 
tion of  infected  air  into  the  uterus,  it  should  not  be  attempted  until 
the'  impracticability  of  the  combined  method  has  been  demonstrated. 
It  is  applicable  chiefly  to  cases  in  which  a  certain  degree  of  uterine 

retraction  has  followed  upon  the 
escape  of  the  amniotic  fluid,* 

The  patient  should  be  placed 
upon  the  back  or  side  ;  the  bladder 
and  rectum  should  be  emptied; 
and  anaesthesia  should  be  pushed 
until  the  action  of  the  abdominal 
muscles  is  suspended.  The  exact 
position  of  the  foetus  should  be 
carefully  ascertained.  The  hand 
should  be  rendered  thoroughly 
aseptic,  and  should  be  passed 
slowly,  after  the  expiration  of  a 
pain,  with  the  fingers  formed  into 
a  cone,  through  the  vagina  and 
cervix,  opposite  the  sacro  -  iliac 
synchondrosis,  upon  the  side  of 
the  child's  feet.  At  the  same 
time  counter-pressure  sliould  be 
maintained  over  the  fundus  uteri, 
to  prevent  rupture  of  the  vaginal 
attachments.  If  the  uterus  begins 
to  contract,  the  fingers  should  be 
spread  out,  and  the  operator  re- 
main passive  until  the  pain  sub- 
sides. 

In  head  presentations,  the  hand  employed  should  be  always  the  one 
which  corresponds  to  the  side  of  the  child's  feet.  In  transverse  presen- 
tations, when  version  is  performed  soon  after  the  rupture  of  the  mem- 
branes, before  retraction  of  the  uterus  has  taken  place  to  any  extent, 
the  choice  of  hands  is  of  little  consequence.  This  is  especially  true  in 
the  dorso-anterior  position.  Thus,  when  the  child  lies  Avith  the  head 
to  the  left,  feet  to  the  right,  and  belly  to  the  rear,  the  right  hand  may 

*  If  the  membranes  are  intact,  and  internal  version  is  chosen  in  place  of  the  bi- 
polar method,  one  of  three  plans  is  open  in  practice:  1.  Boer  recommended  passing 
the  hand  between  the  membranes  and  uterus  to  the  feet  of  the  child,  and  then  rupt- 
uring the  membranes;  2.  Hiiter  seized  the  feet  of  the  child  through  the  mem- 
branes, and  turned  without  rupturing;  3.  Levret  ruptured  the  membranes  at  the 
OS  uteri,  and  introduced  the  hand  during  the  outflow  of  the  water.  The  third  plan 
is  the  one  most  deserving  of  favor. 


Fig.  171.— Version  in  head  presentations. 
(Chailly-Honorg.) 


VERSION.  407 

be  passed  directly  across  the  belly  to  the  extremities  of  the  child,  or 
the  left  hand  may  be  made  to  pass  from  the  breech,  along  the  surface 
of  the  thigh,  to  the  nearest  knee  or  leg.  By  the  latter  method  the 
danger  of  mistaking  an  arm  for  the  leg  is  avoided.  Should,  in  any 
ease,  doubt  upon  this  score  arise,  the  characteristic  differences  between 
the  hand  and  foot  should  guide  us  to  a  correct  diagnosis.  Thus,  the 
wrist  enjoys  greater  mobility  than  the  ankle,  the  fingers  are  longer 
than  the  toes,  the  palm  is  shorter  than  the  sole,  the  position  of  the 
thumb  is  peculiar  to  the  hand,  and  the  pointed  heel  to  the  foot. 

In  the  lateral  position,  the  patient  should  be  placed  upon  the  side 
to  which  the  child's  breech  is  turned,  with  the  buttocks  near  the  edge 
of  the  bed.  Here,  obviously,  the  operator,  standing  in  the  rear  of  his 
patient,  would  use  with  the  greatest  facility  the  hand  corresponding  to 
the  side  upon  which  the  woman  lies  (left  side,  right  hand,  and  vice 
versa).  In  dorso-posterior  positions  especially,  the  advantages  of  such 
a  selection  are  manifest. 

In  easy  versions,  it  is  correct  practice  to  bring  down  one  foot  or 
knee  only.  When  one  extremity  is  left  reflected  upon  the  abdomen, 
the  larger  size  of  the  breech  more  fully  distends  the  cervix,  and  thus 
prepares  the  way  for  the  subsequent  passage  of  the  child's  head.  In 
difficult  cases,  or  when  rapid  delivery  is  to  be  effected,  both  feet  should 
be  seized.  A  single  foot  should  be  held  at  the  ankle  between  the  thumb 
and  fingers.  When  practicable,  the  entire  leg  may  be  grasped  with 
the  closed  hand.  When  it  is  sought  to  turn  by  both  feet,  the  middle 
finger  should  be  placed  between  them,  while  the  ankles  are  held  by  the 
second  and  fourth  fingers. 

While  in  uncomplicated  cases  it  is  not  a  matter  of  great  importance 
which  extremity  is  selected,  it  is  still  proper  to  remember  that,  in  ac- 
cordance with  the  rule  that  the  limb  drawn  upon  moves  forward  under 
the  symphysis,  the  necessary  amount  of  rotation  is  less  when  with  the 
feet  to  the  rear  the  lower,  and  with  the  feet  to  the  front  the  upper,  ex- 
tremity is  subjected  to  traction. 

As  in  the  bipolar  method,  during  the  traction  upon  the  foot  the 
external  hand  should  aid  versioA  by  pressure  upon  the  head  made 
through  the  abdominal  walls  with  the  disengaged  hand. 

When,  in  transverse  presentations,  the  membranes  rupture,  the 
lower  arm  not  unfrequently  becomes  prolapsed  into  the  vagina.  As  a 
rule,  this  complication  does  not  embarrass  version,  though  it  may  prove 
a  hindrance  to  the  introduction  of  the  hand.  It  is  a  good  plan,  in 
arm  presentations,  to  slip  a  noose  of  tape  about  the  wrist,  which  serves 
a  twofold  purpose,  enabling  us  to  draw  the  extremity  up  toward  the 
symphysis,  or  back  against  the  perinasum,  according  as  the  hand  is  to 
be  passed  posteriorly  or  anteriorly,  and  to  hold  the  arm  to  the  side  of 
the  child's  body  during  the  performance  of  version,  thus  avoiding  the 
difficulties  of    arm  delivery  in  the  period  of   extraction.      Dr.  F.  P. 


4:08 


OBSTETRIC  SURGERY, 


Foster,  in  a  case  where  the  mobility  of  the  child  was  unimpeded,  used 
the  prolapsed  arm  as  an  aid  to  version  in  the  followmg  ingenious 
manner :  The  child  lay  with  the  back  to  the  front,  the  head  upon  the 
right  iliac  fossa,  and  the  left  arm  presenting.  With  the  right  hand  in 
the  vagina,  he  seized  the  arm  and  pushed  gently  upward  m  the  di- 


Fig.  172.— Version  in  dorso-anterior  position,  first  stage.    Traction  on  lower  limb. 
(.Faraboeuf  and  Varnier.) 

rection  of  the  humerus.  In  this  way  he  succeeded  in  elevating  the 
cephalic  pole  until  with  the  index-finger  alone  in  the  cervix  uteri  he 
managed  to  reach  the  breech  of  the  child.  With  the  point  of  his 
finger  he  gently  urged  this  along  to  the  mother's  right  side,  and  soon 
encountered  the  left  foot,  which  he  readily  hooked  down  into  the 
vagina.* 

When,  after  rupture  of  the  membranes,  aid  is  not  promptly  ren- 
dered, the  shoulder  becomes  crowded  into  the  pelvic  brim.     If  the 

*  Foster,  On  Prolapse  of  the  Arm  in  Transverse  Presentations,  Amer.  Jour,  of 
Obstet.,  vol.  ix,  p.  203. 


VERSION. 


409 


pains  are  feeble  the  uterus  may  remain  relaxed,  so  that  hours  after- 
ward version  may  be  readily  performed.  If  the  pains  are  good,  how- 
ever, as  the  waters  escape  the  uterus  retracts,  and  finally  becomes  rigid- 
ly applied  to  the  surface  of  the  foetus.  Under  these  conditions,  the 
lower  uterine  segment,  which  contains  the  head  and  shoulder  of  the 


Fig.  173. 


-Version  in  dorso-anterior  position,  second  stage.    Traction  on  lower  limb. 
(FarabcBuf  and  Varuier.) 


child,  is  often  stretched  to  an  extreme  degree  of  tenuity.  Version, 
under  the  circumstances,  is  embarrassed  by  the  difficulty  of  introducing 
the  hand  into  the  uterus  to  seize  the  foot ;  by  the  fact  that  when  trac- 
tions are  made  upon  an  extremity,  in  place  of  the  child  turning  in 
utero^  both  child  and  the  closely  aj^plied  uterus  are  apt  to  move  to- 
gether ;  and  by  the  danger  of  rupture  due  to  the  difficulty  of  lowering 
the  breech  without  simultaneously  increasing  the  pressure  exerted  upon 
the  thinned  lower  segment  by  the  child's  head. 


^^Q  OBSTETRIC  SURGERY. 

In  operating  after  the  retraction  of  the  uterus  has  become  complete, 
the  physician  should  seek  to  effect  the  utmost  relaxation  by  pushmg 
anesthesia  to  complete  insensibility.  The  hand  should  be  mtroduced 
slowly  and  with  the  utmost  gentleness.  Precipitate  action,  or  an  at- 
tempt to  overcome  the  uterine  resistance  by  force,  may  cause  fatal 
rupture  Tlie  external  hand  should  make  firm  counter-pressure  upon 
the  fundus,  to  prevent  the  uterus  from  being  torn  from  the  vagina 
The  seizure  of  the  lower  foot  is  usually  alone  practicable,  himpson,  it 
is  true,  regarded  the  secret  of  success  in  such  cases  as  depending  upon 


Fig.  174.— Version  in  dorso-posterior  position.    Traction  on  upper  limb. 
(Faraboeuf  and  Varnier.) 

making  tractions  with  the  upper  limb,  as  tending  to  rotate  the  body  of 
the  child  upon  its  long  axis,  and  thus  favoring  the  release  of  the  pre- 
senting shoulder  from  its  imprisonment.  However  rational  all  this 
sounds  in  theory,  rotation  within  a  rigidly  contracted  uterus  is  easier 
to  represent  by  diagram  tlian  to  carry  out  in  practice.  The  result  of 
seizing  the  upper  leg  is  usually  to  cross  it  with  its  fellow,  and  to  twist 
the  child's  body  so  as  to  injuriously  compress  the  abdominal  viscera. 
By  making  tractions  upon  the  lower  leg,  the  breech  is  brought  by  the 
shortest  route  to  the  uterine  orifice.  To  be  sure,  by  this  manoeuvre  the 
body  of  the  child  is  bent  laterally,  but  lateral  flexion  does  the  child  no 
harm.     In  case   of  failure  to  effect  version,  a  noose  of  tape  may  be 


VEESION. 


411 


placed  upon  the  foot,  and  the  hand  returned  to  seek  the  other  extrem- 
ity. When  the  foot  is  within  reach,  the  loop  of  the  fillet,  placed  about 
the  fingers,  is  easily  conveyed  upward  to  the  ankle.  When,  however, 
the  foot  is  high  up  in  the  vagina,  where  the  movement  of  the  fingers  is 
impeded,  some  form  of  instrument  is  needed  to  push  the  loop  from  the 


Fig.  175.— Method  of  seizing  the  foot  in  breech  cases.    (Faraboeuf  and  Varnier.) 


fingers  over  the  foot.  Unquestionably  the  most  serviceable  contrivance 
to  this  end  is  the  repositor  of  Carl  Braun,  which  consists  of  a  gutta- 
percha rod  sixteen  inches  in  length,  with  an  aperture  two  inches  from 
the  extremity,  through  which  the  loop  of  a  double  tape  is  threaded. 
When  in  use  this  loop  is  passed  around  the  noose  of  the  fillet,  and  is 
then  reflected  over  the  end  of  the  rod.  Thus  secured,  the  fillet  is  con- 
veyed to  the  position  aimed  at.  Then,  by  loosening  the  ends  of  the 
tape,  which  during  the  upward  movement  are  held  to  the  sides  of  the 


412 


OBSTETRIC  SURGERY. 


rod  by  the  operator's  hand,  and  by  shaking  the  rod,  the  instrument  is 
easily  detached,  and  can  be  withdrawn  without  difficulty. 

If  the  operator  does  not  care  to  release  the  foot,  because  of  the 
difficulties  he  has  encountered  in  getting  possession  of  it,  the  fillet 
may  be  noosed  around  his  arm,  and  thence  be  pushed  upward  over  the 
hand,  to  the  seized  extremity. 

A  device  which  in  many  instances  has  rendered  me  excellent  serv- 
ice, has  consisted  of  an  ordinary  catheter  threaded  with  a  doubled 
piece  of  twine,  so  that  the  loop  projected  from  the  eye  of  the  mstru- 


Fig.  176.— Braun's  repositor. 


Fig.  177.— Catheter  used  as  repositor. 


ment.  This  loop,  after  inserting  the  stylet  into  the  catheter,  I  have 
used  in  precisely  the  manner  laid  down  for  the  employment  of  Braun's 
instrument. 

In  case  the  second  limb  can  not  be  reached,  or  where  traction  upon 
both  extremities  fails  to  bring  the  breech  into  the  cervix,  an  attempt 
should  be  made  to  dislodge  and  elevate  the  presenting  shoulder.  This 
can  sometimes  be  accomplished,  in  accordance  with  the  suggestion  of 
Professor  Goodell,  by  bringing  down  the  upper  arm  and  turning  the 
child  upon  its  long  axis ;  or,  while  the  noosed  foot  is  held  out  of  the 
way  by  the  attached  fillet,  the  hand  corresponding  to  the  child's  head 
may  be  introduced  into  the  vagina  and  employed  to  press  the  present- 
ing part  away  from  the  cervix.  The  raising  of  the  shoulder  should  be 
gradual,  and  should  be  performed  with  the  utmost  gentleness,  as  the 
danger  of  uterine  rupture  is  peculiarly  enhanced  by  the  thinned,  over- 
stretched condition  of  the  lower  segment.  Meantime  a  skilled  assist- 
ant should  exercise  counter-pressure  from  without  upon  the  fundus  of 
the  uterus  and  upon  the  head  of  the  child,  and  aid  the  descent  of  the 
breech  by  rightly  directed  pressure.     Eesolution  to  succeed,  combined 


CRANIOTOMY   AND  EMBRYOTOMY.  413 

with  patience  in   manipulation,  usually  overcomes  the  obstacles  pre- 
sented by  the  most  difficult  cases. 

In  the  few  instances  where  failure  follows  all  attempts  to  accom- 
plish version,  or  where  rupture  is  imminent,  or  where  the  child  is 
known  to  be  dead,  the  obstacle  to  delivery  may  be  overcome  by  decapi- 
tation, and  the  removal  of  the  head  and  trunk  separately. 


CHAPTER  XXII. 

CRANIOTOMY  AND  EMBRYOTOMY. 

Craniotomy. — Indications. — Operation. — Perforators. — Method  of  perforating. — Ex- 
traction after  perforation. — Forceps. — Cephalotribe. — Action  of  the  cephalo- 
tribe. — Objections. — Application  of  the  cephalotribe. — Cranioclast. — Crotchet 
and  blunt  hook. — Cephalotomy. — Embryotomy. — Exenteration. — Decapitation. 

Ckaxiotomy. 

Craniotomy  inch^des  all  the  various  oiierations  employed  to  reduce 
the  dimensions  of  the  child's  head.  Thus  the  term  is  apjilied — 1.  To 
the  perforation  of  the  skull  and  the  evacuation  of  the  brain-contents ; 
and,  2.  To  the  various  procedures  subsequently  adopted  to  further 
minimize  and  extract  the  cranial  walls. 

Indications  for  Perforation. — Perforation  is  resorted  to,  in  cases  of 
mechanical  obstacles  to  delivery,  to  overcome  the  disj^roportion  existing 
between  the  child's  head  and  the  parturient  canal.  As  the  operation 
is  jDerformed  solely  in  the  interests  of  the  mother,  it  possesses  a  wider 
range  of  applicability  when  the  child  is  dead  than  when  still  living. 

Perforation,  in  the  dead  child,  is  allowable  in  difficult  labors  so 
soon  as  temporizing  becomes  dangerous  to  the  mother.  The  mere 
aesthetic  advantage  of  removing  by  forceps  an  unmutilated  child  ought 
not,  if  attended  by  any  risk,  to  be  allowed  to  weigh  with  the  physician 
against  the  welfare  and  safety  of  the  parent. 

If  the  child  is  alive,  the  question  of  perforation  is  one  of  the  most 
serious  that  falls  to  the  lot  of  the  conscientious  physician.  If  the  life 
of  the  mother  is  at  stake,  and  the  sacrifice  of  the  child  is  necessary  to 
her  preservation,  few  would  dispute  at  the  present  day  the  superiority 
of  the  mother's  claim  to  existence.  Still,  it  is  not  sentimentality  to 
feel  that  it  is  an  awful  thing  to  destroy  a  living  child  before  a  clear 
conviction  is  reached  that  conservative  measures,  which  hold  out  the 
hope  of  preserving  both  lives,  are  of  little  or  no  avail.  The  proper 
position,  however,  of  craniotomy,  between  the  C cesarean  section  on  the 
one  hand  and  forceps  and  version  on  the  other,  will  be  discussed  in 
the  section  upon  the  treatment  of  contracted  pelves. 


414  OBSTETRIC  SURGERY. 

Operation.— When  perforation  has  once  been  decided  npon,  there 
sliould  be  no  delay  in  its  execution.  By  delay,  the  very  object  of  its 
performance— viz.,  the  preservation  of  the  life  of  the  mother — is  im- 
periled.* 

The  patient  should  be  placed  in  the  usual  obstetrical  position,  with 
the  knees  flexed  and  the  hips  drawn  over  the  edge  of  the  bed.  Chloro- 
form is  not  requisite.  It  is  useful,  however,  as  a  means  of  saving  the 
mother  from  painful  after-memories.  There  is  no  operation  in  obstet- 
rics in  which  the  result  depends  so  much  upon  thoroughness  in  carry- 
ing out  antiseptic  details.  If  the  head  is  not  fixed  at  the  brim,  it 
should  be  held  firmly  in  position  by  the  hands  of  an  assistant,  through 
the  abdominal  walls,  or  the  child  should  be  turned,  and  perforation  per- 
formed on  the  after-coming  head. 

Complete  dilatation  of  the  cervix  is  not  essential  to  the  execution 
of  the  operation.  If  the  object  is  simply  to  relieve  the  maternal  soft 
parts  from  pressure,  perforation  may  be  performed  at  an  early  stage 
of  labor.  When,  however,  it  is  intended  to  follow  perforation  by  im- 
mediate extraction,  it  is  necessary  to  secure  sufficient  preliminary  dil- 
atation. In  just  this  class  of  cases  I  have  seen  excellent  results  from 
the  employment  of  Dr.  I.  E.  Taylor's  long,  narrow-bladed  forceps, 
which  can  be  passed  through  a  cervix  dilated  to  scarcely  an  inch  and 
a  half  in  diameter.  They  enable  the  operator  to  seize  the  head  and 
use  it  as  a  dilating  wedge  during  and  after  a  pain  {vide  p.  368).  If 
the  cervix  hangs  empty  in  the  pelvis,  and  the  head  can  not  be  moved 
from  the  brim,  Barnes's  dilators  are  often  of  great  service.  Unques 
tionably,  in  many  cases  le=!S  violence  is  done  to  the  mother  if  simple 
perforation  is  resorted  to,  the  brain  evacuated,  and  the  dilatation  of 
the  cervix  left  to  be  accomplished  by  the  pressure  of  the  gradually 
collapsing  head.  This  method,  however,  exposes  the  mother  to  the 
dangers  of  septic  poisoning,  as,  unless  the  pains  should  be  good  and 
delivery  rapid,  decomposition  of  the  foetus  in  utero  speedily  sets  in 
after  perforation. 

Instruments  employed  in  Perforation.— Most  of  the  perforating  in- 
struments in  use  in  this  country  are  patterned,'  with  modifications, 
after  the  scissors  of  Smellie.  Simpson's  perforator  is  the  one  I  have 
been  in  the  habit  of  employing.  As  compression  of  the  handles  causes 
the  separation  of  the  perforating  points,  it  can  be  easily  managed  with 
one  hand.  The  projecting  shoulders,  just  beneath  the  cutting  por- 
tions, prevent  the  instrument  from  penetrating  too  far  into  the  skull. 
The  edges  and  points  of  the  blades  are  rounded,  so  that  they  are  not 
liable  to  injure  the  soft  parts  of  the  mother  during  the  operation.    The 

*  Spiegelberg  states  that  between  the  years  1870  and  1877,  of  thirty-three  cases 
of  perforation,  three  terminated  fatally;  while  in  the  previous  five  years  in  which 
the  operation  was  performed,  at  a  late  period,  of  thirteen  cases,  seven  ended  in 
death.    (Handbuch  der  Geburtshiilfe,  p.  833.) 


CRANIOTOMY   AND  EMBRYOTOMY. 


415 


cliief  objection  to  the  instrument  arises  out  of  these  special  measures 
of  safety,  as,  owing  to  its  bluutness,  considerable  force  has  to  be  em- 


FiG.  178.— Scissors  of  Smellie. 


ployed  to  penetrate  the  skull,  which  increases,  of  course,  the  risk  of 
slipping.     A  better  instrument  is  that  of  Monsieur  Blot.     It  possesses 


Fig.  179.— Simpson's  perforator. 


a  spear-point,  which  makes  it  effective  as  a  perforator.     The  blades, 
when  the  instrument  is  shut,  are  superimposed,  and  are  not  capable 


Fig.  180.— Blot's  perforator. 


of  harming  the  maternal  tissues.     When  the  blades  are  separated,  after 
perforation  has  been  accomplished,  they  readily  cut  the  bony  structure 


Fig.  181.— Hodge's  craniotomy  scissors. 


of  the  skull.     Hodge's  craniotomy  scissors  can  be  used  as  a  perforator, 
and  afterward  to  cut  away  portions  of  bone.     Dr.  T.  G.  Thomas  has 


416  OBSTETRIC  SURGERY. 

devised  a  perforator  with  a  gimlet-like  extremity,  which  is  intended 
to  bore  its  way  into  the  sknll.  The  opening  is  afterward  enlarged  by 
a  knife  which  lies  concealed  and  gnarded  in  the  body  of  the  instrnment 


182.— Thomas's  perforator. 


until  required  for  nse.  Mechanically  considered,  Thomas's  perforator 
is  beyond  reproach.  It  is,  however,  somewhat  more  difficult  to  keep 
in  order  than  those  previously  mentioned. 

The  basylist  of  Professor  Alexander  Simpson  resembles  in  its  gen- 
eral features  the  perforator   of   Dr.    Thomas.     It  is,  however,  much 


Fig.  1S3.— Simpson's  basylist. 


heavier  and  of  more  solid  construction.  In  the  place  of  the  concealed 
knife  it  jDossesses  two  arms,  which,  when  separated  from  one  another, 
act  as  powerful  levers.  The  instrument  is  designed  not  only  to 
perforate  the  cranial  vault,  but,  as  its  name  implies,  to  break  up  the 
base  of  the  skull.  When  this  action  is  rendered  necessary,  the  basylist 
should  be  pushed  inward  to  the  sphenoid  bone,  and  a  point  selected  for 
perforation  in  front  of  the  sella  turcica.     After  boring  well  into  the 


Fig.  184.— Trephine  perforator. 


sphenoid,  the  lever  is  used  to  forcibly  separate  the  base  into  two  por- 
tions. Ordinarily,  the  expulsion  of  the  child  can  then  be  left  to  the 
natural  forces. 

The  Germans  employ  for  the  most  part  a  long  trephining  perfo- 
rator, Avhich  removes  circular  segments  from  the  scalp  and  the  skull. 
The  trephine  leaves  behind  no  splintered  portions  of  bones,  and  makes 


CRANI0T03IY   AND   EMBRYOTOMY. 


417 


an  opening  which  is  not  likely  to  close  from  overlapping ;  but  it  can, 
on  the  other  hand,  be  nsed  only  upon  the  cranial  vault. 

Previous  to  practicing  craniotomy  the  bladder  and  rectum  should 
be  emptied.  The  operator  introduces  his  middle  and  index  fingers 
into  the  vagina,  and  presses  them  firmly  against  the  most  accessible  por- 
tion of  the  child's  head.     Great  care,  at  this  stage,  should  be  exercised 


Fig.  183.— Operation  for  perforating  the  child's  bead. 

to  gain  an  exact  idea  of  the  situation  and  the  extent  of  the  dilatation 
of  the  cervix.  The  operator  then  seizes  the  handle  of  the  perforator 
in  the  right  hand,  and  passes  the  pointed  extremity,  under  the  guid- 
ance of  the  fingei's  of  the  left  hand,  to  the  region  of  the  head  at  which 
it  has  been  decided  the  perforation  is  to  be  made.  If  convenient,  a 
suture  or  a  fontanelle  may  be  selected,  in  place  of  the  bony  table  of 
the  skull.  The  perforator  should  be  pressed  against  the  cranium  with 
a  boring  movement  until  the  cessation  of  resistance  warns  the  operator 
that  the  bony  incasement  has  been  traversed.  In  cases  where  the 
skull  is  unusually  thick  or  hard  this  part  of  the  operation  may  prove 
a  matter  of  some  difficulty.  Care  should  be  taken  to  hold  the  instru- 
ment at  right  angles  to  the  point  of  perforation,  as  otherwise  it  is  apt 
to  glance  from  the  rounded  surface  of  the  head. 
27 


4^j^g  OBSTETRIC  SURGERY. 

If  the  head,  in  place  of  being  fixed  in  the  pelvis,  is  situated  high 
up,  every  precaution  should  be  taken  in  the  operation.  The  head 
should  be  pressed  firmly  against  the  brim  through  the  abdomen  by  an 
assistant.  The  perforator  should  follow  the  axis  of  the  superior  strait. 
The  point  selected  for  perforation  should  be  near  the  symphysis,  as 
the  instrument  is  then  much  less  liable  to  slip  than  if  carried  back- 
ward toward  the  promontory.  The  fingers  of  the  left  hand  should 
keep  constant  guard  upon  its  direction.  Oftentimes,  by  way  of  pro- 
tection, the  operator  introduces  the  entire  half-hand  into  the  vagina. 
After  the  perforator  has  penetrated  the  skull,  the  opening  should  be 
enlarged  by  compressing  the  handles  and  separating  the  cutting 
blades;  then,  allowing  the  latter  to  close,  the  instrument  should  be 
semi-rotated,  and  a  second  cut  made  at  right  angles  to  the  first.  Be- 
fore withdrawing  the  perforator,  it  should  be  moved  about  freely  to 
break  up  the  brain-mass.  The  rapidity  and  completeness  of  the  col- 
lapse of  the  cranial  walls  are,  in  a  measure,  dependent  upon  the  com- 
pleteness of  the  evacuation  of  the  cranial  contents.  Care,  too,  should 
be  taken  to  pass  the  perforator  into  the  foramen  magnum  to  break  up 
the  medulla  oblongata,  and  thus  to  insure  the  death  of  the  child  before 
delivery.  Sometimes  it  is  advantageous  to  wash  out  the  brain-pulp  by 
injecting  a  stream  of  water  into  the  cranial  cavity.* 

In  face  presentations  care  should  be  taken  to  pass  the  perforator 
through  the  frontal  bones,  or  through  an  orbit.  Where  neither  of 
these  points  is,  however,  accessible,  it  is  possible  to  make  the  opening 
through  the  roof  of  the  mouth,  behind  the  nasal  fossae. 

The  perforation  of  the  after-coming  head  is  always  a  matter  of 
considerable  difficulty.  The  point  of  the  perforator  has  to  be  inserted 
obliquely  in  place  of  at  right  angles  to  the  skull,  and  therefore  is  more 
liable  to  glance.  On  theoretical  grounds  it  has  been  recommended  to 
insert  the  instrument  either  between  the  occiput  and  atlas,  or  through 
a  lateral  fontanelle.  In  practice,  however,  such  niceties  are  rarely 
observed. ,  The  operator  simply  passes  the  four  fingers  of  the  left  hand 
under  the,  symphysis  pubis,  and,  while  the  feet  of  the  child  are  drawn 
dowuAvard  and  backward  by  an  assistant,  the  perforation  is  made  at 
any  point  behind  the  ear  at  which  the  manipulation  can  be  most 
easily  effected.  Chailly  recommends  hooking  down  the  chin  of  the 
child,  and  perforating,  as  in  face  presentations,  through  the  roof  of  the 
mouth,  f 

*  Von  Weber  has  shown  that  no  cephalotribe  can  fully  decerebrate  a  perforated 
head,  in  general  only  the  small  part  of  the  brain  being  evacuated.  lie  has  likewise 
demonstrated  that  a  greater  amount  of  compression  can  be  accomplished  in  case  of 
a  fully  than  a  partially  decerebrated  head.  The  head,  therefore,  that  has  been  fully 
emptied  can  be  more  easily  extracted  than  one  that  has  only  been  partially  de- 
prived of  its  contents. 

f  Cohnstein  recommends  cutting  down  upon  the  cervical  and  upper  dorsal  ver- 
tebra%  and  then  openmg  into  the  spinal  canal  by  dividing  the  laminai.     Through 


CRANIOTOMY  AND  EMBRYOTOMY.  419 

The  trephine-perforator  requires  to  be  pressed  firmly  and  steadily 
against  the  parietal  bone.  Sometimes,  when  a  large  scalp-tumor  exists, 
it  is  necessary  to  make  a  preliminary  incision  through  the  integuments. 
The  trephine  is  not  liable  to  slip,  and  is  easily  managed ;  as  it  can  not 
be  used  either  upon  the  after-coming  head  or  in  face  presentations,  and 
as  it  is  difficult  to  keep  clean  and  in  order,  the  less  complicated  lance- 
pointed  instruments  have,  however,  enjoyed  the  preference  in  all  coun- 
tries outside  of  Germany, 

Extraction  of  the  Child  after  Perforation.  —  Formerly,  after  per- 
foration, a  waiting  policy  was  by  many  thought  desirable.  Osborne, 
indeed,  recommended  that  at  least  thirty  hours  be  allowed  to  elapse 
before  delivery,  in  case  craniotomy  was  performed  upon  a  living  child. 
The  grounds  for  favoring  a  temporizing  policy  were  found  in  the 
softening  and  relaxation  of  the  sutures,  and  the  ease  with  which  flat- 
tening takes  place  after  putrefaction  has  once  set  in.  At  present, 
however,  it  is  customary  to  extract  so  soon  as  the  condition  of  the  os 
renders  it  safe  to  resort  to  the  necessary  operative  procedures.  This 
change  in  practice  results  from  altered  views  regarding  the  dangers 
due  to  mere  protraction  of  labor,  to  fear  of  septic  poisoning,  and 
finally  to  improved  methods  now  at  our  disposal  for  the  termination 
of  labor.  Extraction  may  be  performed  by  the  forceps,  the  cepha- 
lotribe,  the  cranioclast,  the  crotchet,  or  the  blunt  hook.  In  some 
cases  version  may  be  employed  with  success.  Each  instrument,  each 
method,  has  its  limitations  and  its  range  of  applicability.  Usually,  in 
extreme  disproportion,  the  operator  finds  it  to  his  advantage  to  have 
at  hand  a  complete  equipment,  and  to  resort  at  different  stages  of 
delivery  to  a  succession  of  operative  manoeuvres.  The  acceptance  of 
single  measures  and  the  Avholesale  condemnation  of  all  others  are  cal- 
culated in  difficult  cases  to  lead  to  embarrassment  and  failure.  A 
study,  therefore,  of  the  capacity  of  the  various  extractive  instruments 
employed  to  deliver  the  perforated  head  is  essential  to  the  formation 
of  correct  judgment  as  regards  practice. 

Forceps. — The  use  of  forceps  as  an  extractive  instrument,  after  per- 
foration, is  recommended  by  Tarnier  as  follows :  "  As  the  application 
of  forceps  has  often  succeeded  in  our  hands,  we  do  not  hesitate  to  say 
that  it  is  a  good  operation,  applicable  above  all  to  cases  in  which  the 
pelvic  contraction  is  not  considerable.  The  forceps  possesses  the  ad- 
vantage of  being  in  the  hands  of  every  physician ;  it  seizes  the  head 
firmly,  and,  by  pressing  the  handles  forcibly  together,  a  sufficient  evac- 
uation of  the  cerebral  contents  is  effected  to  secure  a  marked  flattening 
of  the  cranial  walls.     In  making  prudent  tractions,  one  often  succeeds 

the  opening  a  silver  catheter  can  be  passed  to  the  cranial  cavity,  and  be  used  to 
break  \ip  the  brain-mass,  which  should  be  washed  out  through  the  canal  by  injec- 
tions of  water. — {Yide  Ein  neues  Perforations  Verfahren,  Arch.  f.  Gynaek.,  Bd.  vi, 
p.  505.) 


420  OBSTETRIC  SURGERY. 

in  extracting  the  head  withont  any  harm  to  the  mother ;  the  danger 
begins  only  with  too  violent  tractions."  *  These  remarks  apply,  how- 
ever, to  the  powerful  French  forceps,  which  is  capable  of  exerting  con- 
siderable compressive  force.  Hodge  has  found  his  forceps  useful  under 
similar  conditions.!  The  short  handles  and  the  great  width  between 
the  blades,  in  the  English  forceps,  render  it  useless  as  a  tractor  when 
craniotomy  has  been  performed. 

CepJialofribe.— On  the  6th  of  June,  1829,  Baudelocque,  le  neveu, 
read  before  the  Institut  Royal  de  France  a  memoir  upon  a  new  method 
of  performing  embryotomy.  J  He  first  pictured  the  dangers  incident 
to  all  operations  effected  with  pointed  and  sharp-edged  instruments 
introduced  Avithin  the  uterus.  From  the  statistics  of  the  previous 
sixteen  and  a  half  years  in  the  Maternite,  he  showed  that  half  the 
mothers  thus  operated  upon  died,  and  that  the  shortest  of  these  opera- 
tions lasted  three  quarters  of  an  hour.  He  then  described  an  instru- 
ment he  had  invented,  which  he  termed  the  cephalotribe,  and  repre- 
sented that  with  it  he  could  crush  in  an  instant  the  base  and  parietes 
of  the  fetal  skull,  forcing  the  brain  from  the  orbits,  the  nostrils,  and 
the  mouth,  the  integuments  at  the  same  time  remaining  intact  and 
forming  a  sort  of  sac,  which  sufficed  to  prevent  the  edges  of  the  fract- 
ured bones  from  inflicting  injury  upon  the  soft  parts  of  the  mother. 
The  autlior  furthermore  expressed  his  conviction  that  the  cephalotribe 
was  destined  to  abolish  and  replace  the  perforator  and  the  crotchet, 
and  that  it  could  be  employed  successfully  in  pelves  measuring  but 
two  inches  in  the  contracted  diameter. 

This  early  instrument  was  two  feet  long,  and  weighed  over  seven 
pounds.  In  shape  it  resembled  the  forceps.  To  the  handles  a  crank 
was  attached,  destined  to  aj)proximate  the  enormous  blades  to  one 
another.  The  original  cephalotribe  has  since  been  subjected  to  vari- 
ous modifications,  with  a  view  chiefly  to  the  removal  of  its  repulsive 
appearance.  The  observation  of  Chailly,  in  his  Traite  pratique  des 
accouchements,  1843,  that  perforation  should  always  precede  cepha- 
lotripsy,  led  especially  to  the  construction  of  lighter  and  more  conven- 
ient instruments.  The  dream  of  Baudelocque,  that  the  cephalotribe 
was  destined  to  abolish  the  perforator,  has  never  been  fulfilled. 

The  models  in  use  at  the  present  day  vary  considerably  in  weight, 
the  extent  of  the  pelvic  and  cranial  curves,  and  the  character  of  the 
apparatus  for  producing  compression.  These  different  varieties  are 
simply  expressions  of  the  defective  working  of  the  instrument  itself. 
The  shape  of  the  blades  possesses  the  greatest  importance  practically. 
It  is  to  be  borne  in  mind  that  the  cephalotribe  is  designed  to  act  both 
as  a  crusher  and  as  a  tractor.     Now,  it  so  happens  that  whatsoever 

*  Tarnier,  Diet,  lie  Medecine  et  de  Chirurgie,  art.  Embryotomie,  vol.  xii,  p.  657. 
t  Hodge,  On  Compression  of  the  Petal  Head,  Am.  Jour,  "of  Obstet,  May,  1875. 
X  A.  Baudelocque,  Revue  Med.,  August,  1829,  p.  321. 


CRANIOTOMY  AND  EMBRYOTOMY. 


421 


tends  to  make  it  available  in  the  one  direction  is  obtainable  only  by 
the  sacrifice  of  some  corresponding  advantage  in  the  other.  Thus,  it 
is  evident  that  the  greatest  amount  of  crushing  force  is  exercised  when 
the  blades  run  nearly  parallel  to  one  another ;  but,  without  a  cranial 
curve,  the  blades,  in  place  of  being  applied  to  the  convexity  of  the 
child's  head,  open  like  scissors,  and  thus  are  liable  to  slip,  if  the  in- 
strument is  employed  as  a  tractor.  Again,  as  the  blades  are  usually 
applied  in  the  transverse  or  in  an  oblique  diameter,  it  is  necessary  to 
rotate  the  cephalotribe  to  make  the  flattened  head  correspond  to  the 
flattened  pelvic  diameter,  liotation  of  the  cephalotribe  within  the 
genital  organs  necessitates  an  instrument  without  pelvic  curve ;  and, 
yet,  where  there  is  any  considerable  projection  of  the  promonotory,  a 
straight  instrument  is  apt  to  seize  the  head  upon  its  posterior  aspect 
only,  and  thus  the  head  is  often  forced  from  the  blades,  when  com- 
pression is  used,  like  a  cherry-pit,  to  use  Cazeaux's  simile,  from  between 
the  fingers. 

Fig.  186  represents  the  French  instrument  of  Blot,  which  is  pro- 
vided Avith  a  good  pelvic  curve,  but  the  blades  are  in  close  approxima- 


FiG.  ist3.— CViJhalotribe  of  Blot. 


tion  to  one  another.     In  Scanzoni's  cephalotribe.  Fig.  187,  the  line  of 
greatest  difference  between  the  outer  surfaces  of  the  blades  is  nearly 
The  inner  surface  of  the  blades  is  supplied  with  a  longi- 


two  inches. 


Fig.  187.— Cephalotribe  of  Scanzoni. 


tudinal  ridge  occupying  the  center,  while  the  square  extremities  curve 
sharply  inward  like  pincers.  The  instrument  possesses  a  pelvic  curve 
of  two  and  three  quarters  inches.     When  the  Scanzoni  cephalotribe  is 


4.22  OBSTETRIC  SURGERY. 

applied  to  the  sides  of  the  decerebrated  head,  the  latter  lengthens  in 
the  axis  of  the  instrument,  but  Munde  reports  that  he  has  witnessed 
the  failure  of  the  instrument  to  seize  the  head  securely  in  the  Wurz- 
burg  clinic,  in  three  cases  out  of  four.     Fig.  188  represents  a  cephalo- 


Fio.  188.— The  author's  cephalotribe. 


tribe  made  for  me  some  years  ago  by  Messrs.  Tiemann  &  Co.,  which 
has  met  with  considerable  favor  in  New  York  and  its  vicinity.  It  has 
a  cephalic  curve  of  two  inches  and  a  quarter,  measuring  from  the 
outer  surfaces  of  the  blades.*  The  pelvic  curve  is  three  inches  and 
two  lines  in  extent.  These  measurements  are  similar  to  those  of  the 
Prague  instruments  of  Seyfert  and  Breisky.  The  blades  are  fenes- 
trated and  grooved  upon  the  inner  surfaces.  The  advantages  of  an  in- 
strument thus  modeled  are  obvious.  It  is  possible  with  its  aid  to  seize 
the  head  when  movable  above  the  pelvic  brim.  As  the  points  ap- 
proach each  other  closely  after  compression  of  the  head  is  completed, 
the  instrument  becomes  a  perfect  tractor,  holding  the  head  as  securely 
as  an  ordinary  forceps.  Its  construction  is,  however,  virtually  the 
abandonment  of  two  favorite  but  chimerical  ideas  regarding  the  ca- 
pacity and  mode  of  action  of  the  cephalotribe,  viz..  that  it  is  capable  of 
flattening  the  head  so  that  the  latter  can  be  drawn  through  a  pelvis 
measuring  but  two  inches  in  the  conjugate  diameter,  and  that  this  can 
be  accomplished  by  rotating  the  instrument,  as  we  have  mentioned,  so 
as  to  make  the  flattened  head  correspond  to  the  shortened  diameter  of 
the  pelvis. 

The  actual  result  of  compression  by  means  of  the  cephalotribe  was  long  a 
matter  of  dispute.  Baudelocque,  with  his  ponderous  instrument,  claimed  to 
have  been  able  to  instantly  crush  the  skull,  including  the  base.  Kilian  t  relates 
that  in  his  first  case  of  cephalotripsy  he  succeeded  in  breaking  up  the  skull  by 
a  single  application  into  fifty-four  pieces.  Von  Weber,  however,  made  a  large 
number  of  experiments  upon  still-born  children,  employing  for  purposes  of  com- 

*  The  advantages  of  making  the  blades  parallel  to  one  another  are  rather  ap- 
parent than  real ;  for,  however  effectively  compression  with  such  an  instrument 
may  be  applied,  the  head  acts  as  a  wedge,  producing  a  separation  at  the  extrem- 
ities proportioned  to  the  absence  of  the  cephalic  curve.  Breisky  and  Seyfert  have 
insisted  that  it  is  better  to  transfer  the  greatest  width  between  the  blades  from 
the  extremities  to  the  points  at  which  they  come  into  immediate  contact  with  the 
child's  head. 

\  KiLiAX,  Organ  f.  die  gesammt.  Medeein,  Bd.  ii,  p.  279. 


CRANIOTOMY  AND  EMBRYOTOMY.  423 

parison  instruments  of  various  patterns,  and  found  that  in  no  case  did  he  suc- 
ceed in  fracturing  the  bones  of  the  skull.  Even  after  the  complete  evacuation 
of  the  cerebral  contents  the  bones  would  bend,  but  did  not  fracture.  The  result 
was  different,  however,  in  cases  where  the  cephalotribe  was  emploj-ed  in  actual 
labor,  where  the  head  was  subjected  at  the  same  time  to  pressure  from  the  uter- 
ine and  pelvic  walls.  Under  such  circumstances  the  bones  certainly  may  break, 
if  they  do  not  invariably.  Fractures  he  found,  in  fact,  less  common  than  simple 
incurvations.  Where  a  fracture  took  place  in  one  bone  it  rarely  extended  to 
contiguous  ones,  and,  in  general,  contributed  but  little  toward  the  actual  reduc- 
tion of  the  head.  Winckel  *  presented  three  heads  to  the  Obstetrical  Society  of 
Berlin,  upon  which  the  cephalotribe  had  been  used  to  facilitate  delivery.  Com- 
pression, in  these  cases,  had  been  employed  in  several  diameters,  and  each  time 
the  cracking  sound  elicited  could  have  led  one  to  suj)pose  tliat  the  bones  were 
being  reduced  to  small  pieces,  yet  subsequent  examination  showed  that  only  a 
single  bone,  and  that,  usually,  according  to  the  position  of  the  head,  a  parietal 
bone,  was  broken  to  any  extent,  while  the  opposite  side,  generally  the  basis 
cranii,  was  but  slightly  ruptured.  Now,  the  greatest  amount  of  compression 
effected  by  the  cephalotribe  does  not  exceed  two  to  two  and  a  quarter  inches. 
The  bizygomatic  diameter,  indeed,  which  measures  three  inches,  is  not,  in  or- 
dinary cephalotripsy,  attacked  at  all.t 

It  has  always  been  objected  to  the  cephalotribe  that  its  application  in  the 
transverse  diameter  increases  the  length  of  the  head  in  the  antero-posterior 
diameter,  or  precisely  where  the  pelvis  is  the  narrowest,  and  thus  adds  to  the 
difficulty  of  delivery.  This  is  no  doubt  true  when  the  head  is  fixed  in  the  pel- 
vis, a  fact  which  should  lead  us  to  give  the  preference  to  other  instruments  for 
extraction  after  engagement  has  taken  place.  Above  the  brim,  the  cephalotribe 
seizes  the  head  usually  in  an  oblique  diameter,  so  that  the  compensation  takes 
place  in  the  opposite  oblique  diameter.  If  the  head  is  seized  in  the  transverse 
diameter,  it  may  easily  be  rotated  into  an  oblique  diameter.  Sometimes  the 
compressed  head  rotates  spontaneousl}',  so  that  the  cephalotribe  comes  to  oc- 
cupy the  conjugate,  a  thing  obviously  possible  only  in  moderate  degrees  of 
contraction.  Artificial  rotation  of  the  cephalotribe  into  the  conjugate  is  dan- 
gerous, and  should  under  no  circumstances  be  attempted.  It  must  be  borne  in 
mind  that  the  axis  of  the  instrument  is  in  a  line  between  the  upper  border  of 
one  blade  and  the  lower  blade  of  the  other,  and  not  in  one  drawn  transversely 
between  them.  If  spontaneous  rotation  occurs,  the  instrument  should  be  re- 
moved, and  the  cranioclast  employed  as  a  tractor.  Extraction  with  a  powerful' 
instrument  like  the  cephalotribe  can  not  be  safely  undertaken  when  the  points 
of  pressure  from  the  blades  are  the  soft  tissues  between  the  symphysis  and  prom- 
ontory. 

Thus  we  find  the  cephalotribe  useful  in  compressing  the  head 
before  it  becomes  fixed  at  the  brim.  It  is,  moreover,  advantageous  as 
a  tractor  in  moderate  degrees  of  pelvic  contraction.  With  two  and 
three  quarters  inches  in  the  conjugate,  the  limit  for  its  safe  employ- 
ment is,  as  a  rule,  reached.  Of  course  it  is  understood  that  other 
factors  than  the  pelvic  diameters  may  influence   the   result.      Thus, 

*  Winckel,  Kephalotripsie,  Monr.tsschr.  f.  Geburtsk.,  Bd.  xxi,  p.  81. 
f  Fritsch,  Der  Kephalothryptor  und  Braun's  Cranioclast,  Volkraann's  Samml. 
klin.  Vortr.,  No.  127,  p.  870. 


424  OBSTETRIC  SURGERY. 

much  dej^ends  upon  the  size  of  the  child's  head,  the  resiliency  of  the 
cranial  bones,  and  the  relations  of  the  pelvic  diameters  to  one  another. 
It  is  not  disputed  that  the  cephalotribe  is  capable,  if  force  is  used,  of 
accomplishing  delivery  through  a  smaller  space  than  the  one  given  ; 
but  the  severe  injuries  to  the  maternal  tissues  which  the  instrument  is 
apt  to  inflict,  even  when  every  caution  is  exercised,  make  its  employ- 
ment dangerous  in  the  higher  degrees  of  pelvic  deformity. 

In  1863  Pajot  *  published  a  paper  in  which  he  stated  that,  while  in  cases  of 
distortion  in  which  the  narrowing  did  not  exceed  two  and  a  half  inches  cepha- 
lotripsy  was  a  favorable  operation,  requiring  the  exercise  of  no  great  amount  of 
force,  and  but  two  or  three  applications  of  the  instrument,  below  that  point  he 
regarded  it  as  nearly  as  dangerous  as  the  Cajsarean  section.  In  the  belief  that 
these  results  were  due  to  rude  attemjits  to  drag  an  imperfectly  reduced  head 
through  the  contracted  space,  he  proposed  that  in  all  cases  below  two  and  a  half 
inches  no  tractions  should  be  made,  but,  so  soon  as  dilatation  had  ])roceeded  far 
enough  to  permit,  perforation  should  be  performed,  whereupon  complete  dilata- 
tion would  occur  more  speedily,  and  cephalotripsy  might  be  begun  at  an  early 
period  of  labor — a  point  in  itself  of  considerable  importance.  While  applying 
the  cephalotribe,  one  or  two  assistants  should  make  counter-pressure  over  the 
pubes  to  steady  the  head.  The  blades  should  be  introduced  as  high  as  possible 
by  depressing  the  handles.  After  compressing  the  head,  rotation,  if  it  has  not 
occurred  spontaneously,  should  be  cautiously  attempted.  The  slightest  obstacle 
should,  however,  be  the  signal  for  suspending  rotation  and  withdrawing  the 
instrument,  when  Nature  usually  brings  about  rotation  with  astonishing  ra- 
pidity The  instrument  should  then  be  reapplied,  and  the  compression  re- 
peated. The  same  process  should  be  gone  through  with  a  third  time,  after 
which  the  woman  should  be  placed  in  a  convenient  posture  and  given  bouillon 
to  drink.  Then,  governed  by  the  state  of  the  pulse  and  the  general  appearance 
of  the  patient,  the  quiet  or  excitement  manifested,  the  weak  or  energetic  char- 
acter of  the  pains,  the  cephalotribe  should  be  applied  two  or  three  times  every 
two,  three,  or  four  hours,  leaving  the  expulsion  of  the  foAus  entirely  to  Nature. 
M.  Pajot  has  never  found  more  than  four  applications  of  this  procedure  neces- 
sary, while  one  or  two  have  generally  sufficed.  After  the  passage  of  the  head, 
one  or  two  applications  of  the  instrument  are  required,  as  a  rule,  to  reduce  the 
thorax.  To  be  successful,  however,  it  is  requisite  that  the  operation  should  be 
resorted  to  at  an  early  period  of  labor,  when,  as  a  rule,  not  more  than  six  to 
eighteen  hours  are  needed  for  Nature  to  expel  the  uterine  contents.  Tractions 
should  be  employed  only  in  those  cases  to  which  one  is  called  at  a  late  period, 
after  the  powers  of  Nature  are  exhausted.  Objections  to  this  plan  of  Pajot  have 
been  made  as  follows :  That  there  is  risk  of  rupture  of  the  uterus  from  the  pro- 
longation of  the  labor;  that  the  uterus  is  exposed  to  injury  from  the  spiculai  at 
the  point  of  perforation;  that,  owing  to  the  great  rapidity  with  which  decompo- 
sition takes  place  after  cephalotripsy,  the  bones  of  the  skull  are  liable  to  become 
denuded  of  their  coverings;  and,  finally,  that  after  a  given  period  the  mem- 
branes become  so  far  destroyed  as  no  longer  to  protect  the  uterus  from  its  de- 
composing contents.  Pajot  replies  by  adducing  seven  cases  in  which  he  em- 
ployed his  method.     Five  of  the  cases  were  successful,  and  two  terminated 

*  Pajot,  De  la  cpphalotripsie  repetec  sans  tractions,  Paris,  1863. 


CRANIOTOMY   AND  EMBRYOTOMY.  425 

fatally.  The  highest  degree  of  deformity  for  which  he  operated  was  a  case  in 
which  the  contracted  diameter  was  something  less  than  an  inch  and  a  half. 
The  patient  died  from  ruptured  uterus,  due,  according  to  M.  Pajot,  to  attempts 
made  previous  to  his  arrival  to  perform  cephalotripsy  with  a  badly  constructed 
instrument. 

The  application  of  the  cephalotribe  does  not  differ  from  that  of 
the  forceps.  AVhere  perforation  lias  been  performed,  spicule  of  bone 
should  be  carefully  removed  with  the  fingers.  Confirmatory  evidence 
as  to  the  direction  of  the  head  may  be  obtained  by  exploring  the  cra- 
nial cavity  with  the  finger,  as,  in  this  way,  the  exact  position  of  the 
base  and  vault  may  be  determined.  Great  caution  should  be  exer- 
cised during  the  introduction  of  the  blades  not  to  injure  the  vaginal 
or  uterine  tissues.  It  is  not  always  easy  to  lock  the  instrument  after 
the  blades  have  been  adjusted.  The  left  blade  is  easily  placed,  but 
often  the  right  blade  is  with  difficulty  brought  forward  to  the  cor- 
responding transverse  or  oblique  diameter.  Compression  should  be 
made  slowly,  and  the  opening  made  by  the  perforator  should  be  care- 
fully guarded  lest  cutting  portions  of  bone  protrude.  Extraction 
should  take  place  under  the  guidance  and  protection  of  the  fingers  of 
the  left  hand. 

Sometimes  the  cephalotribe  is  used  to  compress  and  extract  the 
after-coming  head  in  cases  of  moderate  pelvic  contraction.  Under 
such  circumstances  perforation  is  usually  not  a  prerequisite.  The 
cephalotribe  seizes  the  head  securely,  and  acts  with  great  power  upon 
the  basis  cranii.  The  increased  diameters  of  the  head  accommodate 
themselves  more  readily,  too,  to  the  long  diameters  of  the  pelvis  than 
in  cranial  presentations.  When  the  head  is  retained  in  the  uterus 
after  it  has  become  detached  from  the  body,  it  should  be  held  by  an 
assistant  through  the  abdominal  Avails,  and  steadied  by  a  crotchet  in- 
troduced into  the  foramen  magnum,  or  fixed  into  an  orbit,  or  in  the 
lower  jaw.  The  cephalotribe  may  then  be  applied  to  complete  the  ex- 
traction. 

Cranioclast. — It  is  necessary  to  distinguish  between  two  instru- 
ments, each  of  which  bears  the  name  of  cranioclast.  The  original 
model  was  the  device  of  Sir  J.  Y.  Simpson,  and  was  intended  by  him 
to  replace  the  cephalotribe.  It  is  substantially  a  powerful  pair  of 
craniotomy-forceps.  The  larger  blade,  which  is  intended  to  be  placed 
upon  the  outer  surface  of  the  head,  is  fenestrated  and  grooved.  The 
smaller  one,  for  introduction  into  the  perforated  skull,  is  solid,  and 
supplied  with  ridges  which  fit  into  the  grooves  upon  the  opposite 
blade.  The  two  blades  articulate  by  means  of  a  button-lock.  By  a 
twisting  movement,  the  cranioclast,  when  applied,  can  be  employed  to 
wrench  off  the  bones  of  the  calvarium,  different  portions  of  the  skull 
being  seized  successively  with  the  view  of  accomplishing  that  result. 
As  the  fractured  bones  are  covered  by  the  scalp,  they  are  prevented 


426 


OBSTETRIC  SURGERY. 


from  inflicting  injury  during  the  subsequent  course  of  delivery.     But 
the  cranioclast  is  not  only  of  use  in  breaking  up  the  cranial  vault,  it  is 
likewise  the  most  effective  of  all  the  instruments  employed  for  extrac- 
tion of  the  perforated  head. 

The  principal  defect  of  the  Simpson 
cranioclast  is  that  it  attempts  to  combine 
in  the  same  instrument  the  functions  of 
crusher  and  tractor.  Now,  as  in  the  ceph- 
alotribe,  the  devices  which  make  it  the 
most  effective  instrument  in  the  one  di- 
rection weaken  its  utility  in  the  other, 
Braun's  modified  cranioclast  is  intended 
to  serve  purely  as  a  tractor.  All  idea  of 
its  undertaking  to  break  up  the  skull  is 
discarded.  The  work  of  compression  and 
disarticulation  is  left  to  the  counter-press- 
ure of  the  pelvic  walls,  and  to  the  em- 
ployment of  craniotomy-forceps  and  the 
cephalotribe.  The  term  cranioclast  is 
therefore  a  misnomer.  Munde's  proposed 
substitute  of  "  craniotractor "  is  descrip- 
tive of  its  real  action.  Yet  the  modifica- 
tions of  Braun  were  as  simple  as  they 
have  proved  appropriate.  A  pelvic  curve 
has  been  given  to  the  blades ;  the  handles 
have  been  lengthened  so  that  the  lock, 
even  when  the  instrument  is  introduced 
high  up,  is  outside  the  vulva ;  and,  finally, 
an  apparatus  for  compression  has  been 
added.  The  advantages  of  Braun's  cranio- 
clast over  its  rival,  the  cephalotribe,  are 
as  follows :  it  is  of  comparatively  small 
size ;  again,  one  branch  lies  inside  the 
head,  in  a  space  not  otherwise  occupied; 
the  outer  branch  imbeds  itself  in  the  soft 
coverings  of  the  head,  and  thus  is  pro- 
After  a  few  tractions  the  cranioclast  occu- 
pies the  middle  of  the  pelvis,  where  it  can  be  so  guarded  by  the  hand 
that  it  need  not  even  come  into  contact  with  the  vaginal  walls ;  as  the 
head  is  drawn  into  the  pelvis,  the  pressure  is  not  concentrated  at  one 
or  two  points,  bat  is  diffused  over  the  entire  pelvic  rim ;  the  head  is 
therefore  able  to  mold  itself  to  the  shape  of  the  pelvis.  Subsequent 
to  the  use  of  Braun's  cranioclast,  extensive  lacerations  and  injuries  to 
the  maternal  organs  are  rarely  found.  The  cranioclast  takes  firm  hold 
of  the  head.     It  never  slips  during  extraction.     It  is  not  apt  to  tear 


Fig.  189.— Simpson's  cranioclast. 


tected  from  doins  harm. 


CRANIOTOMY  AND  EMBRYOTOMY. 


427 


away  when  the  cranium  and  scalp  are  seized  together.  The  most 
secure  grip  is  obtained  when  the  inner  blade  is  passed  to  the  base  of 
the  skull,  while  the  outer  one  is  applied  to  the  face  or  over  an  ear. 


Fig.  190.— Braun's  cranioclast. 


Should  the  portion  grasped  tear  away,  the  readjustment  of  the  instru- 
ment upon  another  part  of  the  skull  is  easy.  Thus,  the  inner  blade 
can  be  turned,  of  course,  in  any  direction  without  difficulty,  while  the 


Fig.  191.— Head  of  child  after  delivery  with  the  cranioclast.    (Simpson.) 

outer  blade  is  easily  disengaged  from  the  scalp-tissues  and  changed  in 
its  position  by  direct  pressure  from  the  fingers  and  slight  leverage 
movements  of  the  handle. 

The  cranioclast  may  often  advantageously  be  used  as  a  tractor  in 


42S  OBSETRTIC  SURGERY. 

cases  where  the  head  has  been  previously  crushed  and  flattened  by  the 
cephalotribe ;  but,  where  extraction  with  the  hitter  is  rendered  difficult 
by  slipping,  or  by  the  inability  of  the  operator  to  make  the  altered 
diameters  of  the  head  correspond  to  those  of  the  contracted  pelvic 
space,  the  immense  superiority  of  the  cranioclast  consists  in  the  capa- 
city to  seize  the  head  antero-posteriorly,  and  thus  to  bring  its  length- 
ened diameter  into  the  transverse  space  of  the  pelvis. 

The  cranioclast  enables  us  to  extend  the  limits  of  safe  delivery  far 
beyond  what  would  be  admissible  with  the  cephalotribe,  as  with  its  aid 
it  is  possible,  after  the  partial  or  complete  removal  of  the  flat  bones  of 
the  skull,  to  tilt  the  chin  downward,  and  draw  the  base  by  the  edge 
through  the  conjugate.  In  this  way  craniotomy  may  be  resorted  to 
in  pelves  measuring  less  than  two  and  three  fourths  inches  antero-pos- 
teriorly. Indeed,  Barnes  claims  that  one  inch  and  three  fourths  in  the 
conjugate  and  three  inches  in  the  transverse  diameter  furnish  sufficient 
space  for  a  successful  operation.* 

The  proceeding  to  be  pursued  in  these  difficult  cases  is  as  follows : 
After  perforation  introduce  a  forceps-blade  under  the  scalp,  and  detach 
the  latter  as  far  as  possible  from  the  cranial  bones ;  break  up  and  wash 
out  the  entire  brain-mass ;  seize  the  parietal  bones  beneath  the  scalp 
with  a  good  pair  of  craniotomy-forceps,f  and  break  them  away  piece- 
meal by  a  twisting  movement  of  the  wrist.  The  withdraAval  of  the 
fractured  bones  is  always  a  matter  of  delicacy.  Unless  the  soft  parts 
are  carefully  guarded  by  the  hand,  the  maternal  tissues  are  apt  to  be  cut 
and  lacerated  by  the  sharp  edges  and  splintered  corners  of  the  bones. 
Skene  J  has  found  it  a  great  aid,  in  some  cases,  to  use  a  large-sized 
Sims  speculum  to  bring  the  head  into  view,  and  to  go  through  the 
various  steps  of  craniotomy  with  the  guidance  of  the  eye.  The  sug- 
gestion is  an  excellent  one ;  but  when  the  head  is  high  up,  as  is  the 
rule  in  difficult  cases,  I  have  not  always  found  it  practicable  to  expose 
in  this  way  the  presenting  part.  Horwitz  *  recommends,  in  difficult 
cases  of  the  unexpanded  cervix,  to  perforate  through  a  large  Fergusson 
speculum. 

After  the  removal  of  the  parietal  bones,  the  fenestrated  blade  should 
be  placed  under  the  chin,  or  in  the  mouth,  while  the  smaller  one  is  in- 
troduced inside  the  perforation,  and  applied  so  that  the  frontal  bones 
are  included  in  the  grasp  of  the  instrument.     The  blades  should  then 

*  Barnes,  Obstetric  Operations,  p.  402.  For  discussion  of  this  point,  see  Treat- 
ment of  Contracted  Pelves. 

t  Meigs's  craniotomy-forceps  has  been  largely  used  in  America,  and  may  be 
confidently  recommended.  There  are  two  forms,  one  straight  and  the  other  curved. 
Dr.  Taylor's  modification  consisted  chiefly  in  increasing  the  length  of  the  instru- 
ment, so  as  to  render  it  more  available  in  operations  at  the  superior  strait. 

t  Skene,  Trans,  of  the  Am.  Gyna;c.  Soc,  vol.  ii. 

»  Horwitz,  tber  ein  Perforations  Verfahren,  Ztschr.  f.  Geburtsh.  u.  Gynaek., 
Bd.  iv,  p.  1. 


CRANIOTOMY  AND  EMBRYOTOMY. 


429 


be  screwed  tightly  together  by  means  of  the  apparatus  for  compression, 
and  the  head  turned  so  that  its  bizygomatic  diameter  is  brought  into 
the  transverse  diameter  of  the  pelvis.  As  the  distance  between  the 
orbital  plates  and  the  chin,  including  the  instrument,  does  not  exceed 


Fig.  19^. — Meigs's  crauiotomy-forceps  (modified  by  Professor  I.  E.  Taylor). 

two  inches,  and  the  width  of  the  base  is  only  about  three  inches,  !t  is 
evident  that,  in  skillful  and  experienced  hands,  this  method  is  capable 
of  almost  indefinite  extension. 

After  delivery  of  the  head,  the  extraction  of  the  body  may  still 
cause  difficulty.  If,  then,  through  an  opening  made  with  a  perforator 
between  the  clavicle  and  shoulder-blade  the  smaller  blade  be  intro- 
duced, and  the  outer  blade  be  applied  on  the  back,  so  that  the  two  in- 
clude the  spine,  the  cranioclast  will  seize  the  trunk  firmly,  and  is  capa- 
ble of  exerting  great  force  as  a  tractor. 

Crotchet  and  Blunt  HooTc. — As  tractors,  neither  of  these  instru- 
ments is  much  in  vogue  at  the  present  day.  It  is  well,  however,  to 
become  familiar  with  their  uses,  as  we  are  not  always  placed  where  we 
can  have  a  complete  armamentarium  at  our  disposal. 


Fio.  193.— Crotchet. 


The  crotchet  is  a  steel  hook,  with  a  sharp-pointed  extremity.  The 
shaft  is  either  straight  or  curved  to  adapt  it  better  to  the  convexity  of 
the  head.  In  craniotomy  the  instrument  is  often  useful  in  breaking 
up  the  brain.     It  may  be  inserted  into  an  orbit  when  it  is  desired  to 


430  OBSTETRIC  SURGERY. 

bring  tlie  base  of  the  skull  end  on  into  the  pelvis.  In  default  of  either 
cranioclast  or  cephalotribe,  it  may  be  employed  to  extract  the  perfo- 
rated head.  To  this  end  it  should  be  passed  through  the  opening  and 
its  point  inserted  into  one  of  the  bones  of  the  cranial  vault.  Two  fin- 
gers of  the  left  hand  are  then  passed  to  the  outer  surface  of  the  skull, 
to  serve  as  a  guard  and  to  make  pressure  against  the  point  fixed  upon 
the  inner  surface.  If  much  resistance  is  met  with,  the  part  is  apt  to 
tear  away,  and  a  new  hold  has  to  be  taken.  When  portions  of  bone  are 
broken  away  they  should  be  removed  with  the  fingers,  to  prevent  their 
doing  harm.  The  process  is  often  tedious,  and  in  unskillful  hands  is 
not  devoid  of  danger.  When  the  bones  of  the  vault  yield  under  trac- 
tion, a  more  effective  grip  may  sometimes  be  obtained  by  fixing  the 
crotchet  at  the  foramen  magnum  or  the  sella  turcica.  Or,  in  place 
of  introducing  the  instrument  into  the  skull,  it  is  sometimes  inserted 
outside,  behind  the  ear^  into  the  mastoid  process,  or  into  the  occiput, 
near  the  foramen  magnum.  The  blunt  hook,  though  not  indispensa- 
ble, is  capable  of  rendering  valuable  service  in  delivering  the  head  after 
the  performance  of  craniotomy.     Dr.  I.  E.  Taylor  gives  the  preference 


Fig.  194.— Dr.  Taylor's  right-angled  blunt  hook. 


to  a  right-angled  instrument.  The  blunt  hook  can  not,  of  course,  be  at- 
tached to  flat  surfaces  of  bone.  It  may  be  used,  however,  to  draw  down 
the  chin,  or  it  may  be  thrust  into  an  orbit.  Where  perforation  has  been 
made  upon  the  after-coming  head,  the  blunt  hook  may  be  introduced 
through  the  opening  and  traction  made  directly  upon  the  base  of  the 
skull.  In  difficult  cases,  delivery  of  the  trunk  is  sometimes  favored  by 
tractions  made  by  a  blunt  hook  inserted  under  the  posterior  shoulder. 

Fer^io;^.— Version,  with  extraction  by  the  feet,  with  or  without 
cephalotripsy,  has  been  warmly  commended  by  Bertin,  Tarnier,*  and 
Taylor,t  while  it  has  been  condemned  in  harsh  terms  by  others.  AVhere 
it  is  practicable  to  perforate  and  turn  early  in  labor,  at  a  time  when 
version  is  easy,  the  method  has  the  advantage  of  bringing  the  longest 
diameter  of  the  head  into  correspondence  with  the  long  diameter  of 
the  pelvis,  and  favoring  the  molding  of  the  head  to  the  shape  of  the 
canal  it  has  to  traverse.  At  the  same  time  it  avoids  the  dangers  of 
contusing  the  soft  parts  incident  to  the  use  of  the  cephalotribe.  Dr. 
Taylor  recommends  combining  propulsion  above  the  pubes  with  trac- 
tions made  upon  the  extremities. 

*  Tarnier,  Diet,  de  medecine  et  de  chirurgie,  art.  Embrvotomie,  t.  xii  p  668 
+  Taylor.  What  is  the  Best  Treatment  in  Contracted  Pelves  ?  Trans,  of  the 
Aew  York  Acad,  of  ]Med.,  1875. 


CRANIOTOMY  AND  EMBRYOTOMY. 


431 


Great  ingenuity  has  been  exerted  to  devise  some  good  way  to  overcome  the 
difficulty  which  grows  out  of  the  defectiveness  of  the  preceding  measures  in 
acting  directly  upon  tlie  base  of  the  skull.  Cephalotomy,* 
or  the  removal  of  the  head  by  segments,  has  been  pro- 
posed as  a  substitute  for  perforation  and  cephalotripsy. 
Van  Huevel's  forceps-saw  divides  the  head  from  crown 
to  base  into  two  halves.  Tarnier's  forceps-saw  removes 
from  the  head  a  triangular  segment,  the  apex  of  which  is 
cut  from  the  skull-base.  Dr.  Barnes  f  has  suggested  the 
application  of  Braxton  Hicks's  wire  ecraseur  to  successive 
portions  of  the  head.  Hubert's  transforaieur  is  designed 
to  bore  through  the  sphenoid,  and  thus  to  destroy  the  re- 
sistance of  the  base.  The  sphenotribes  of  Valette,  Hiiter, 
and  the  Lollines,  are  a  combination  of  the  cephalotribe 
and  the  transfarateur.  Notwithstanding  the  principle  of 
cephalotomy  is  mechanically  correct,  the  operation  has 
never  met  with  any  general  acceptance,  partly  owing  to 
the  high  price  and  complicated  structure  of  most  of  the  yig.  195.  —  Segment  re- 
instruments  required  for  its  performance,  ^d  perhaps  in  nier*^'^forceps*'-  Sw 
part  to  the  fact  that,  in  the  higher  degrees  of  pelvic  de-  (P-  Thomas.) 
formity,  where  their  advantages  over  the  more  familiar 

methods  would  be  theoretically  most  complete,  the  bulky  nature  of  the  forceps- 
saws  and  the  sphenotribes  interfere  with  their  employment.  Tlie  favorable 
reports  made  by  their  inventors  of  the  results  they  have  personally  obtained 
render,  however,  a  reference  to  the  subject  necessary. 


Embkyotomt. 

In  a  literal  sense,  embryotomy  includes  all  the  graver  opera- 
tions designed  to  diminish  the  volume  and  resistance  of  the  foetus. 
Custom  has,  however,  restricted  the  term  to  those  operations  only 
which  are  performed  upon  the  trunk  of  the  child.  It  is  used,  there- 
fore, as  a  rule,  in  contradistinction  to  craniotomy,  and  not  in  its  ge- 
neric sense. 

Indications  for  Embryotomy. — 1.  In  extreme  degrees  of  pelvic  con- 
traction, where  the  size  of  the  body  obstructs  delivery.J  2.  In  fetal 
malformations,  with  abdominal  enlargement  due  to  pathological  con- 
ditions of  the  more  important  viscera,  and  in  cases  of  extraordinarily 
developed  children.  3.  In  neglected  transverse  presentations,  in  which 
version  is  impossible,  or  at  least  can  not  be  performed  without  en- 
dangering greatly  the  life  of  the  mother. 

*  Tarnier,  Diet,  de  Medeeine  et  de  Chirurgie,  art.  Embryotoniie,  p.  680. 

f  Barnes,  Obstetric  Operations,  p.  411. 

X  It  has  been  said  that,  in  cases  which  do  not  demand  the  Ciesarean  section,  this 
indication  is  not  likely  to  arise.  In  the  extraction  of  the  child's  body,  however, 
through  a  small  justo-minor  pelvis,  which  required  for  its  completion  upward  of 
twenty-five  minutes,  post-tnortem  examination  showed  more  extensive  disturbances 
from  arrested  pelvic  circulation,  due  to  compression  from  the  child's  body,  than 
from  the  lesions  arising  out  of  the  performance  of  craniotomy. 


432  OBSTETRIC  SURGERY. 

Embryotomy  includes  two  operative  measures,  viz.,  exenteration 
and  decapitation. 

Exenteration.— By  exenteration  we  mean  the  opening  of  one  of  the 
large  cavities  of  the  trunk  and  the  removal  of  the  contained  viscera. 
It  is  most  commonly  indicated  in  transverse  presentations,  where  de- 
c.ipitation  is  not  easy  to  perform,  as  in  cases  of  extreme  pelvic  con- 
traction with  the  head  high  up  above  the  pelvis.  The  opening  may  be 
made  by  means  of  a  pair  of  curved  scissors  or  the  ordinary  perforator. 
The  same  precautions  against  injury  of  the  maternal  tissues  have  to 
be  observed  as  in  craniotomy.  In  shoulder  presentations  an  assistant 
should  press  the  fundus  of  the  uterus  downward.  The  operator  at  the 
same  time  thrusts  the  perforator,  or  the  scissors,  between  the  ribs,  and 
then  enlarges  the  opening  by  turning  the  instrument  so  as  to  make  a 
second  incision  at  right  angles  to  the  first.  Next,  splintered  portions 
of  bone  should  be  carefully  broken  away  wdth  the  fingers,  until  the 
opening  becomes  sufficiently  extensive  to  permit  the  introduction  of 
the  half-hand.  In  tearing  awJly  the  viscera,  the  fingers  may,  if  neces- 
sary, be  aided  by  the  volsella-forceps.  The  abdominal  cavity  may 
be  reached  directly  through  the  thorax  by  perforation  of  the  dia- 
phragm, or  a  fresh  opening  may  be  made  through  the  abdominal  walls. 

After  evisceration,  the  reduced  bulk  of  the  child  renders  it  pos- 
sible to  proceed  directly  to  seize  the  feet  and  perform  version.  This 
method  is,  however,  generally  difficult,  and  endangers  the  distended 
cervix  and  lower  uterine  segment.  If,  therefore,  the  shoulder  is  high 
up,  the  breech,  which  is  easily  reached,  should  be  drawn  down  with 
the  fingers  or  the  blunt  hook,  in  imitation  of  the  mode  of  delivery  in 
spontaneous  version.  When,  however,  an  arm  presents,  and  the  shoul- 
der is  crowded  into  the  pelvis,  the  child  may  be  drawn  through  doubled 
upon  itself,  as  in  spontaneous  evolution. 

Decapitation. — Whenever,  in  neglected  transverse  presentations,  the 
neck  can  be  easily  reached,  decapitation  furnishes  the  simplest  and 
mildest  plan  for  overcoming  the  difficulties  which  prevent  delivery. 


Fig.  196.— Braun's  decapitating  hook. 


Decapitation  may  be  effected  in  a  number  of  different  ways  : 
1.  Draw  upon  the  prolapsed  arm  to  bring  the  neck  well  down  and 
within  reach.     Pass  the  finger  or  a  blunt  hook  around  the  neck,  and 


CRANIOTOMY  AND  EMBRYOTOMY. 


433 


then,  carefully  guarding  the  points,  divide  with  a  strong  pair  of  scissors 
by  a  series  of  short  movements  the  soft  structures  and  the  vertebral 
column. 

2.  In  many  cases  the  division  of  the  neck  can  be  advantageously 
accomplished  by  Braun's  decollator.  This  in:^trument  is  a  modifica- 
tion of  the  blunt  hook.  The  terminal  portion  is,  however,  bent  at 
nearly  an  acute  angle. 
It  is  likewise  flattened 
from  side  to  side,  and 
ends  in  a  button-shajDed 
extremity.  The  handle 
is  fixed  at  a  right  angle, 
and  is  capable  of  im- 
parting to  the  instru- 
ment powerful  leverage 
movements.  In  em- 
ploying the  decollator, 
the  index  and  middle 
fingers  of  the  left  hand 
should  encircle  the 
child's  neck  from  be- 
hind, while  the  thumb 
is  placed  upon  the  an- 
terior surface.  The 
neck  should  then  be 
firmly  grasped  and 
drawn  down  into  the 
pelvis  as  far  as  jdos- 
sible.  The  decollator 
should  be  passed  up 
flat  under  the  sym- 
pliysis  pubis  along  the 
thumb  of  the  opera- 
tor, until  the  button- 
end   has   advanced  far 

enough  to  be  turned  to  the  rear  over  the  neck.  Finally,  the  in- 
strument should  be  seized  by  the  handle  with  the  right  hand,  and 
rotated  to  and  fro,  while  tractions  are  simultaneously  made  in  a  down- 
ward direction.  It  is  surprising  how  quickly,  as  a  rule,  the  spinal 
column  may  be  divided  by  this  manoeuvre.  After  the  separation  of 
the  vertebrae,  care  must  be  taken  not  to  draw  down  with  too  much 
force,  lest  the  integuments  and  soft  structures  yield  suddenly,  and 
violence  be  done  by  the  rapid  withdrawal  of  the  instrument.  This 
accident  may  be  avoided  by  using  moderate  tractions  and  dividing  the 
last  remnant  of  the  tissues  with  a  pair  of  scissors.  The  decapitating 
2S 


FiQ.  197.— Braun's  method  of  decapitation. 


434 


OBSTETRIC  SURGERY. 


hook  of  Ramsbotliam,  which  is  curved,  and  has  a  cuttiug  edge  upon  the 
concave  part,  is  more  difficult  to  apply,  and  is  a  less  safe  instrument  in 
unskillful  hands. 

3.  Pajot  originated  an  ingenious  method  of  decapitation,  which,  in 
default  of  special  instruments,  is  capable  of  rendering  valuable  service. 
It  consists  in  passing  a  strong  cord  around  the  child's  neck,  and,  by  a 
sawing  movement,  cutting  through  the  parts.  The  vagina  should  be 
protected  by  a  speculum  from  the  friction  produced  by  the  to-and-fro 
movement  of  the  string.  The  chief  difficulty  of  the  operation  lies  in 
getting  the  string  around  the  neck.  Pajot  caused  a  groove  to  be  made 
upon  the  concave  surface  of  the  blunt  hook  which  forms  a  constant 
attachment  to  one  of  the  handles  of  the  ordinary  French  forceps. 
Through  this  groove  he  passes  a  string,  to  the  end  of  which  he  fastens 
a  round  lead  bullet ;  when  the  blunt  hook  is  adjusted  about  the  child's 
neck,  the  weight  of  the  bullet  draws  the  cord  downward  so  that  it  can 
be  reached  by  the  hand  of  the  operator.  Dr.  Kidd  recommends  attach- 
ing a  string  to  an  elastic  catheter  armed  with  a  strong  stylet ;  then, 


»fiA<VA>y\fW(>» 


Fig.  198.— Embryotome  of  P.  Thomas. 

after  imparting  to  the  instrument  the  proper  curve,  it  should  be  passed 
around  the  chdd  s  neck,  and,  as  it  is  withdrawn,  the  string  should  be 
used  to  drag  a  strong  cord  or  the  chain  kraseur  into  place 

Still  more  ingenious  is  the  embryotome  of  Pierre  Thomas,  consist- 
ing of  two  blades  modeled  after  a  somewhat  expensive  instrument  de- 
vised by  M.  larnier.  The  curved  blade  should  be  passed  posteriorly 
opposite  the  sacrum.  The  straight  blade  should  be  introduced  in  front 
directly  beneath  the  pubic  bones.     When  adjusted,  the  extremities  of 


CRANIOTOMy  AND  EMBRYOTOMY. 


435 


the  blades  are  in  apposition.  Both  blades  contain  a  grooved  canal.  A 
piece  of  whalebone  armed  with  an  ivory  knob  is  then  introduced  into 
the  canal  of  the  straight  blade,  while  a  long,  flexible  piece  of  whale- 
bone provided  with  an  ivory  ring  is  passed  into  the  canal  of  the 
posterior  curved  blade.     The  descent  of  the  posterior  whalebone  fur= 


Fig.  199.— Embrj'otome  adjusted  around  the  neck  of  the  child. 

nishes  the  evidence  that  the  canals  of  the  two  blades  are  in  apposition^ 
and  that  the  longer  piece  has  entered  the  posterior  canal.  When  the 
circuit  is  completed,  a  loop  of  cord  is  passed  through  an  eyelet  in  the 
end  of  the  whalebone,  and  serves  as  an  attachment  to  a  chain-saw, 
which,  as  it  is  drawn  upward,  leaves  the  groove  and  encircles  the  child's 
neck.  In  decapitating  the  child  by  a  to-and-fro  movement,  the  soft 
parts  are  protected  by  the  blades  of  the  embryotome. 


^3g  OBSTETRIC  SURGERY. 

CHAPTEK  XXIII. 

CESAREAN  SECTION.-OPERATIONS  OF  THOMAS  AND  PORRO. 

CjEsareaii   section.  -  Ilislory.  -  Indications.-Operation.-After-treatment.-Prog- 
nosis.— Operation  of  Porro,— Operation  of  Thomas. 

The  Cesarean  Section. 

The  term  Ccesarean  section  is  applied  to  cases  in  which  the  foetus 
is  removed  from  the  mother  by  au  incision  made  through  the  abdomi- 
nal and  uterine  walls. 

Although  the  operation  pretends  to  great  antiquity,  the  earlier  his- 
tories are  probably  of  mythical  origin.  The  supposed  references  in 
the  Talmud  are,  according  to  Rodenstein,  mistranslations  of  the 
text.  The  same  authority  suggests  that  even  the  lex  regis,  attributed 
to  Numa  Pompilius,  which  makes  it  obligatory  upon  the  physician  to 
remove  the  child  by  abdominal  section  in  case  the  mother  dies  during 
pregnancy,  was  really  added  to  the  Roman  law  in  the  middle  ages,  with 
the  intention  of  giving  force  to  the  decretals  of  the  Church,  which 
sought,  through  the  Caesarean  section  upon  the  dead,  to  rescue  the 
child  for  the  rite  of  baptism  before  its  life  became  extinct.  During  the 
sixteenth  century  there  seems  no  reason  to  doubt  the  authenticity  of 
certain  cases  of  laparotomy,  performed  during  the  life  of  the  mother, 
for  the  removal  of  the  foetus  in  extra-ut3ri.i3  pregnancies.  In  1581 
Francois  Rousset*  published  the  historias  of  fourt3en  successful  Caesa- 
rean sections,  six  of  which  were  said  to  have  been  performed  upon  the 
same  individual.  These  cases  were  repeated  from  hearsay,  and  from 
accounts  taken  from  letters  written  by  friends.  Their  genuineness 
was  challenged  at  the  time  of  publication  by  the  opponents  of  the 
operation,  and  they  are  now  generally  regarded  as  resting  upon  ques- 
tionable authority.  The  first  operations  mentioned  after  the  publica- 
tion of  Rousset's  work  are  said  to  have  proved  fatal.  The  earliest  well- 
authenticated  record  of  Cassarean  section  conies  to  us  from  Germany. 
It  was  performed  in  Wittenberg,  by  Trautmaun,  in  IGIO.  The  patient 
lived  from  the  21st  of  April  to  the  IGth  of  May.  Scarcely  any  doubt 
was  entertained  of  her  recovery,  when  she  was  suddenly  seized  with  a 
fainting-fit  and  died,  contrary  to  all  expectation,  in  about  half  an 
hour. 

Until  a  very  recent  date  the  Caesarean  section  was  Justly  regarded  as 
one  of  the  most  hazardous  operations  in  surgery.  Michaelis  f  collected 
258  authentic  cases,  of  which  54  per  cent  ended  in  recovery.     Kayser  \ 

*  Rousset.  Traite  nouveau  de  I'hysterotomotokie,  on  enfantement  Cesarienne. 
f  Michaelis,  Abhjmdlungen  aus  dem  Gebiete  der  Geburtshtilfe,  1833. 
X  Kayser,  De  Eveiitu  Sectionis  Caisariie. 


*'  CESAREAN  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.    437 

added  80  new  cases  to  those  reported  by  Michaelis,  and  reduced  tlie 
recoveries  to  38  per  cent.  Mayer*  gathered  1,605  cases,  with  54  per 
cent  recoveries.  Pihan-Dufeilhay  f  collected  88  cases,  published  be- 
tween 1845-'49,  of  which  57  per  cent  ended  in  recovery.  Dr.  Harris 
(1888)  gathered  with  great  industry  the  histories  of  153  cases  per- 
formed by  the  older  methods  in  the  United  States,  56  of  which,  or 
nearly  37  per  cent,  ended  in  recovery.  Under  this  showing  it  will 
be  seen  that  at  best  fully  one  half  of  all  the  Ctesarean  operations  ended 
fatally.  Spaeth,  writing  before  the  conservative  operation  of  Siinger 
had  changed  the  results  of  practice,  said  that  there  had  not  been  a 
single  case  in  the  lying-in  hospital  in  Vienna  during  this  century  in 
which  the  mother  had  survived.  Baudon,  writing  in  1873,  said,  "  In 
Paris  there  has  not  been  one  successful  case  in  eighty  years,  though  in 
the  present  century  the  operation  has  been  performed  on  perhaps  as 
many  as  fifty  women." 

The  responsibility  for  these  results  was  due,  in  the  first  place,  to 
septic  infection,  the  evils  of  which  were  especially  experienced  in  hos- 
pital practice,  and  to  the  postponement  of  the  operation  until  death 
impended.  What  was  possible  after  eliminating  these  elements  of 
danger  even  with  barbaric  methods  of  surgery,  was  shown  in  a  rejiort 
by  Harris,  J  in  which  he  gave  the  history  of  nine  women  whose  wombs 
had  been  ripped  up  in  advanced  pregnancy  by  the  horns  of  infuriated 
cattle,  with  the  survival  of  four  women  and  four  children.  Again, 
in  six  cases  of  self-inflicted  Caesarean  section,  five  of  the  women  re- 
covered. 

Of  hardly  less  importance  in  blocking  progress  was  the  persistent 
superstition  that  the  alternating  contractions  and  relaxations  of  the 
uterus  forbade  the  employment  of  the  uterine  suture;  Consequently, 
the  uterine  incision  was  left  to  gape,  and  closure  in  favorable  cases  was 
usually  effected  by  an  adhesive  inflammation  which  united  the  uterine 
to  the  abdominal  walls.  According  to  Sanger,  only  one  instance  is 
known  where  complete  union  took  place  throughout  the  length  and 
depth  of  the  wound.  Sometimes  cicatricial  tissue  extended  the  length 
but  not  through  the  thickness  of  the  incision,  and  was  of  a  callous 
consistency ;  in  others  the  line  of  union  was  at  points  of  extreme 
tenuity,  disposing  to  hernial  protrusions,  and  in  subsequent  pregnan- 
cies to  rupture ;  while  in  others,  again,  union  took  place  at  intervals 
only,  with  the  formation  of  fistulous'  openings,  communicating  with 
the  abdominal  walls,  or  with  circumscribed  cavities  in  the  abdominal 
inclosure.  Yet  so  strong  are  old  prejudices,  that  even  recently  Porro's 
proposition  to  avoid  the  risks  of  the  gaping  of  the  uterine  wound  by 

*  Mayer,  notice  by  Bromeisl,  Wien.  med.  Woch.,  1868,  No.  67 
f  PiHAN-DuFEiLHAY,  Arch.  Gen.  de  Med.,  1861,  t.  ii. 

I  Harris.  Cattle-horn  Lacerations  of  the  Abdomen  and  Uterus  in  Pregnant 
Women,  Am.  Jour.  Obst,  July,  1887. 


^3s  OBSTETRIC  SURGERY. 

the  removal  of  the  entire  uterus,  was  accepted  as  a  surgical  necessity. 
Indeed,  it  has  been  in  this  country  chiefly,  where  tradition  exerts  a 
feeble  influence,  that  prior  to  the  appearance  of  Sanger's  exhaustive 
monoo-raph  the  suture  enjoyed  anything  like  a  fair  trial,  and  Sanger 
strongly  re-enforced  his  argument  in  favor  of  its  employment  by  the 
successes  obtained  through  its  agency  by  Polin,  Brickell,  Jenks,  and 

Lundgren. 

The  improved  Cajsarean  section  of  the  present  day  is  based  upon 
an  early  resort  to  the  operation  before  the  patient's  strength  is  ex- 
hausted by  lengthy  labor  and  the  futile  resort  to  measures  to  extract 
the  child  by  the  natural  passages ;  upon  the  complete  closure  of  the 
uterine  wound,  and  upon  the  employment  of  aseptic  precautions,  such 
as  are  commonly  used  in  abdominal  surgery.  Sanger  is  justly  regarded 
as  its  founder,  for  though  others,  and  notably  Harris,  in  this  country, 
had  insisted  upon  the  importance  of  the  same  factors,  the  great  body 
of  the  profession  was  still  engaged  in  the  task  of  showing  that  the 
Ctesarean  section  had  profited  nothing  by  the  recent  advances  in  surgi- 
cal science  when  Sanger's  work  *  was  published.  The  latter  at  once 
awakened  the  dormant  interest  of  the  profession  on  the  subject.  Its 
challenge  to  test  the  question  of  the  practicability  of  the  Csesareau 
operation,  as  modified  by  modern  principles,  met  with  a  ready  re- 
sponse, and  the  triumphant  reinstatement  of  the  measure  in  the  do- 
main of  legitimate  surgery  followed.  Since  then  the.  mutilating  oper- 
ation of  Porro  has  been  restricted  within  narrow  limits,  and  the  croak- 
iugs  of  the  anti-Coesarean  school  are  no  longer  heard. 

Indications  for  the  Caesarean  Section.  —  As  even  the  improved 
Caisarean  section  is  a  hazardous  operation,  its  performance  is  chiefly 
justifiable  in  cases  in  which  craniotomy  and  the  delivery  of  the  child 
by  the  natural  passages  involve  the  life  of  the  mother  in  still  greater 
peril.  It  is  indicated,  therefore,  in  extreme  degrees  of  pelvic  contrac- 
tion, in  the  case  of  solid  tumors  which  encroach  upon  the  pelvic 
space,  and  in  advanced  carcinomatous  degeneration  of  the  cervix. 

The  Caesarean  section  is  permissible  if  the  mother  is  moribund 
and  the  cliild  is  known  to  be  alive,  where  rapid  delivery  by  the  natural 
passages  is  impossible  It  may  be  undertaken  at  the  mother's  request 
if  otherwise  delivery  can  not  be  accomplished  without  the  sacrifice  of 
the  child.  If  in  any  case  the  decision  is  left  to  the  physician,  he 
should  regard  the  welfare  of  the  mother  as  of  paramount  importance. 
It  has  been  said  that  if  a  woman,  knowing  herself  to  be  incapable  of 
bearing  living  children,  exposes  herself  to  the  repetition  of  pregnancy, 
it  becomes  the  duty  of  the  physician  to  perform  the  Cesarean  section 
in  the  interest  of  the  child.     The  duty  of  the  physician  is,  however, 

*  Sanger,  The  Ca?s.arean  in  Cases  of  Uterine  Fibromata  ;  Criticisms,  Studies,  and 
Propositions  for  the  Improvement  of  the  Caesarean  Section. 


CiESAREAN  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.     439 

to  his  patient.  He  is  not  -to  constitute  himself  either  judge  or  exe- 
cutioner. 

Operation.  —  The  success  of  Caesarean  section  depends  in  large 
measure  upon  the  control  which  the  obstetric  surgeon  possesses  over 
the  conditions  under  which  the  operation  is  performed.  When  it  is 
practicable,  the  patient  should  be  prepared  for  the  operation  by  full 
baths,  by  disinfecting  vaginal  douches,  by  laxatives,  by  diet,  and  by 
tonics. 

The  most  suitable  time  to  operate  is  after  dilatation  has  begun,  but 
previous  to  the  rupture  of  the  membranes :  after  dilatation,  because  it 
is  desirable  to  provide  a  free  outlet  for  the  uterine  discharges  subse- 
quent to  the  operation,  and  because  the  retraction  of  the  uterus  after 
delivery,  which  furnishes  the  most  efficient  means  of  controlling 
hemorrhage  from  the  uterine  wound,  is  best  secured  if  the  operation 
is  performed  at  a  time  when  the  contractions  are  strong  and  frequent ; 
previous  to  rupture,  because  there  is  then  greater  probability  of  finding 
the  child  alive  and  the  maternal  tissues  uninjured.  Unless,  too,  the 
head  or  breech  protrudes  spontaneously  through  the  incision  made  in 
the  uterine  wall,  the  delivery  is  much  more  readily  performed  while 
the  membranes  are  iutact  than  after  the  uterus  has  retracted  firmly 
down  upon  the  child's  body. 

The  necessary  preparations  should  meantime  be  made,  and  selected 
assistants  should  have  explained  to  them  their  respective  duties.  There 
should  be  one  assistant  to  take  charge  of  the  anesthesia,  one  to  hold 
the  uterus  after  it  has  been  turned  out  of  the  abdominal  cavity,  one  for 
the  instruments,  one  to  take  charge  of  the  newborn  child,  and,  if  still, 
to  aid  in  its  resuscitation,  and  a  trained  nurse  to  wash  and  keep  account 
of  the  sponges. 

Few  instruments  are  required.  The  entire  armamentarium  should 
consist  of  one  or  two  scalpels,  a  pair  of  blunt-pointed  scissors,  a  half- 
dozen  compression  forceps,  a  needle-holder,  curved  needles,  an  irri- 
gator, a  powder-blower,  aseptic  towels,  and  vessels  containing  an  abun- 
dance of  warm  carbolized  water.  The  sponges  should  be  aseptically 
cleaned*  and  carefully  counted.  A  piece  of  rubber  tubing  will  be 
needed  to  place  around  the  lower  uterine  segment  to  control  the  hem- 
orrhage when  the  uterus  is  incised.  For  ligatures,  silver  wire,  silk,  and 
catgut  have  each  their  advocates.  At  present  silk  is  favored  by  Sanger, 
Kelley,  and  others,  as  the  preferable  material — a  choice  in  which  I 

personally  concur.      At  the  time  of  operation  instruments,  sponges, 

» 

*  To  render  sponges  aseptic  they  should  first  be  boiled  in  a  weak  solution  of 
soda,  and  washed  out  in  boiled  water.  They  should  then  be  soaked  for  two  hours 
in  a  solution  of  permanganate  of  potash  (1 :  4,000),  and.  after  repeated  washings  in 
a  four-per-cent  solution  of  hyposulphite  of  soda,  to  which  three  to  four  per  cent  of 
muriatic  acid  has  been  added,  should  be  preserved  in  a  five-per-cent  solution  of 
carbolic  acid.     Zweifel,  Arch.  f.  Gyn.,  vol.  xxxi,  p.  204. 


440  OBSTETRIC  SURGERY. 

wire,  and  silk  sliould  be  jilaced  in  a  two-per-cent  solution  of  carbolic 
acid. 

The  operator  and  bis  immediate  assistants  should  thoroughly  wash 
their  hands  and  forearms  with  soap  and  water.  The  nails  should  be 
cleaned  with  a  nail-brush  and  nail-cleaner,  and,  after  removing  sapona- 
ceous materials  with  alcohol,  the  hands  and  arms  should  be  bathed  for 
several  minutes  in  1 :  1,000  solution  of  corrosive  sublimate.  During  the 
operation  clean  white  aprons  should  be  worn. 

Preliminary  to  the  operation  the  patient's  bowels  and  bladder 
should  be  emptied,  and  the  vagina  should  be  douched  with  a  five-per- 
cent solution  of  carbolic  acid.  During  the  induction  of  angesthesia 
pains  should  be  taken  to  make  sure  that  the  auscultiitory  signs  of  foetal 
life  are  present.  After  the  patient  has  been  placed  upon  the  table 
the  pubes  should  be  shaved,  and  the  abdomen  should  be  cleansed  in 
the  usual  manner  with  soap-suds,  corrosive- sublimate  solution,  and 
ether. 

The  abdominal  incision  should  be  made  to  extend  from  a  point 
above  the  pubes  to  one,  three,  or  four  inches  above  the  navel.  At  this 
stage  it  is  convenient  to  pass  a  half-dozen  long  wire  sutures  through 
the  upper  portion  of  the  incision.  For  the  moment  the  ends  should  be 
left  free.  The  child  can  be  removed  from  the  uterus  in  situ,  in  which 
case  an  assistant  should  take  pains  to  keep  by  external  pressure  the 
abdominal  walls  in  close  contact  with  the  surface  of  the  uterus ;  but  it 
is  a  great  convenience  first  to  turn  the  uterus  out  of  the  abdominal 
cavity.  This  is  accomplished  without  much  difficulty,  by  first  tilting 
the  uterus  so  as  to  cause  it?  left  border  to  present  at  the  incision,  and 
then  pressing  the  abdomiail  walls  backward  over  the  uterus.  As  it 
emerges  the  assistant  should  envelop  it  in  a  warm  carbolized  towel, 
and  hold  it  at  nearly  right  angles  to  the  abdomen.  The  operator  now 
tightens  the  sutures  in  the  abdominal  incision  to  retain  the  intestines, 
and  places  a  flat  sponge  beneath  the  abdominal  walls  behind  the  uterus 
to  prevent  the  entrance  of  fluids  into  the  peritoneal  cavity.  The  rub- 
ber tubing  should  be  placed  loosely  around  the  lower  uterine  segment 
beneath  the  presenting  part,  or,  where  there  are  plenty  of  assistants, 
manual  compression  applied  to  the  cervix  may  be  employed  to  control 
hajmorrhage.  I  prefer,  instead  of  beginning  at  the  fundus,  by  a  series 
of  rapid  strokes  first  to  make  a  small  incision  down  to  the  membranes 
m  tlie  median  line  just  above  the  lower  segment,  and  then  to  extend  the 
incision  rapidly  upward  with  a  pair  of  blunt-pointed  scissors.  If  the 
placenta  is  encountered,  it  should  be  detached  with  the  fingers  and 
pushed  to  one  side.  The  uterine  incision  should  be  between  four  and 
five  inches  in  length.  If  the  membranes  are  intact,  they  should  be  rupt- 
ured and  the  child  should  be  rapidly  extracted.  The  rubber  ligature 
should  be  tightened,  if  necessary,  to  control  bleeding.  As  the  uterus 
retracts,  the  assistant  sees  that  the  abdominal  incision  is  kept  in  close 


CESAREAN  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.    441 

contact  with  the  uterine  surface.  AVith  a  little  care  no  blood  or  fluid 
need  obtain  entrance  into  the  abdomen  during  the  entire  operation. 

In  many  cases  the  membranes  peel  off  intact  with  slight  traction, 
and  come  away  with  the  placenta.  Adherent  portions  of  decidua 
should  be  carefully  detached  with  the  fingers.  I  have  found  it  easy  to 
wash  out  the  uterine  cavity  with  a  disinfectant  fluid,  by  placing  the 
irrigator  nozzle  in  the  wound  and  pressing  the  cut  surfaces  together 
while  loosening  for  the  moment  the  elastic  ligature.  The  pressure  of  the 
hands  prevents  hfemorrhage,  and  the  stream  passes  out  unimpeded 
through  the  vagina.  When  this  has  been  done  the  uterine  cavity 
should  be  sponged  nearly  dry  and  the  inner  surface  powdered  over 
with  iodoform  by  means  of  an  insufflator. 

The  uterine  incision  should  be  closed  by  two  sets  of  sutures,  a 
stronger  one  of  wire,  silk,  or  catgut  for  the  muscular  strvictures,  and  a 
fine  one  of  silk  or  catgut  to  approximate  the  peritoneal  borders.  The 
muscular  sutures  should  be  introduced  one  half  inch  from  the  borders 
of  the  incision,  and  passed  obliquely  downward  to,  but  not  including, 
the  decidua.  Of  these,  eight  to  twelve  are  usually  necessary.  For  the 
peritonteum  I  have  used  an  interrupted  suture  of  fine  silk,  and  have 
employed  with  great  satisfaction  the  Lembert  stitch  to  secure  close 
union.  Leopold  advocates  catgut  for  both  deep  and  superficial  sutures, 
on  the  ground  that  they  produce  less  subsequent  irritation ;  but  care 
must  be  taken  to  secure  catgut  of  good  quality,  and  to  tie  the  deep 
sutures  with  three  knots. 

After  the  suturing  is  completed  a  hypodermic  injection  of  the 
fluid  extract  of  ergot  should  be  made  into  the  skin  of  the  outer  surface 
of  the  thigh.  The  elastic  ligature  should  then  be  loosened,  and 
manual  compression  maintained  until  firm  contractions  have  been 
secured.  After  replacing  the  uterus,  the  abdominal  wound  should  be 
closed  without  haste,  and  with  punctilious  care.  A  full  antiseptic 
dressing  should  be  applied.  The  patient,  finally,  should  be  placed  in 
bed  with  hot  bottles  around  her,  and,  in  case  of  failing  heart-action, 
the  usual  restoratives  should  be  applied. 

As  vomiting  after  the  Cassarean  section  is  rare,  the  administration 
of  liquid  food  by  the  stomach  is  possible  almost  from  the  first.  Tym- 
panites is  sometimes  distressing,  but  can  often  be  relieved  by  injections 
of  soap-suds  in  chamomile  infusion,  while  in  severer  cases  a  calomel 
laxative  may  be  administered  (gr.  ijss  every  five  hours  until  action  is 
produced).  The  abdominal  stitches  should  be  removed  from  the 
twelfth  to  the  fourteenth  day.  In  favorable  cases  the  patient  may  sit 
up  by  the  middle  of  the  third  week. 

Trained  nursing,  frequent  visits,  and  promptness  in  meeting  emer- 
gencies count  for  much  in  securing  favorable  results. 

In  conclusion,  it  may  be  proper  to  state  that  if  the  patient's  con- 
dition at  the  outset  is  fairly  good,  and  the  operation  is  performed  with 


442  OBSTETRIC  SURGERY. 

every  attention  to  detail,  such  as  a  well-equipped  hospital  renders 
possible,  and  the  after-management  is  intelligently  conducted,  the 
prognosis  is  hardly  doubtful.  Recovery  will  almost  certainly  follow, 
and  a  new  triumph  will  add  to  the  fame  of  Sanger. 

But  if  the  patient  has  been  operated  upon  in  her  own  home,  after  a 
lingering  labor,  without  needed  assistance,  perhaps  by  the  light  of  a 
kerosene  lamp  and  with  preparations  of  a  make-shift  character,  and 
after  the  work  is  ended  she  is  left  to  the  care  of  ignorant,  prejudiced 
persons,  it  may  be  proper  to  call  the  operation  by  the  name  of  Sanger, 
but  recovery,  if  it  occurs,  must  be  regarded  as  partaking  of  the  nature 
of  a  miracle. 

Porro's  Operation,  or  Ovaro-Hystorectomy.  —  The  characteristic 
feature  of  the  Porro  operation  consists  in  the  removal,  after  the  per- 
formance of  the  C^esarean  section,  of  both  uterus  and  ovaries.  As 
the  result  of  experiments  upon  animals,  its  theoretical  practicability 
was  demonstrated  as  early  as  1769  by  Cavallini,  and  later,  in  1823,  by 
Blundell.  G.  Pli.  Michaelis,  in  1809,  after  referring  to  the  danger 
from  reaction  following  injury  to  any  of  the  abdominal  viscera,  goes 
on  to  say :  "  That  the  danger  specially  depends  upon  this  reaction, 
we  see  not  only  from  the  often  greater  associated  disorders  in  other 
organs,  but  from  the  experience  that,  when  the  uterus  has  been  re- 
moved so  that  the  reaction  in  other  organs  falls  away,  the  danger 
appears  to  be  much  lessened.  Several  cases  are  known  where  the 
uterus  has  been  excised  by  ignorant  persons  without  the  occurrence 
of  violent  disturbances  [Zufalle].  ...  It  is  a  question,  therefore, 
whether  the  Caesarean  section  would  not  be  rendered  less  dangerous 
by  connecting  with  it  the  extirpation  of  the  uterus."  The  ablation  of 
the  uterus  after  Cassarean  section  was  not,  however,  actually  executed 
upon  the  living  human  female  until  1868.  The  first  operation  was 
performed  by  Dr.  Horatio  R.  Storer,  of  Boston,  in  the  case  of  a  patient 
whose  delivery  was  rendered  impossible  by  the  natural  passages,  owing 
to  a  large-sized  fibro-cystic  tumor  blocking  up  the  pelvic  cavity.  The 
haemorrhage  which  followed  the  incision  into  the  uterine  cavity  prov- 
ing frightful.  Dr.  Storer  ligatured  the  cervix,  and,  having  applied  the 
chain  ecraseiir,  slowly  removed  the  mass.  Both  the  child  and  placenta 
were  in  a  state  of  decomposition.  The  patient  lived  sixty-eight  hours. 
At  the  time  of  the  occurrence  the  hardihood  of  the  operator  was  the 
subject  of  a  good  deal  of  unfavorable  comment. 

In  1874  Professor  Edward  Porro,  of  Pavia,  having  succeeded  in 
preserving  the  lives  of  animals  from  which  he  had  removed  the  gravid 
uterus,  decided  that,  as  soon  as  a  chance  offered,  he  would  add  to  the 
Caesarean  section  as  a  completive  measure  the  ablation  of  the  uterus 
and  its  appendages.  The  sought-for  opportunity  presented  itself  on 
the  31st  of  May,  1876.  The  patient  had  a  rachitic  pelvis,  with  an 
antero-posterior  diameter  reduced  to  one  inch  and  a  half.     The  child 


CESAREAN  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.     443 

was  extracted  living,  and  the  mother  survived.  After  the  publication 
of  Porro's  report,  the  two  Brauns  and  Spaeth,  of  Vienna,  where  the 
Cassarean  section  had  been  jDroverbially  fatal  (no  case  saved  in  this 
century),  resolved  to  give  the  new  operation  a  trial.  Spaeth  led  off 
with  a  success  in  June,  1877. 

In  1888  C.  Braun  von  Fernwald  had  operated  twelve  times  with 
eight  recoveries.  Breisky  operated  seven  times.  All  his  cases  recovered. 
So,  too,  Leopold  has  had  eight  cases,  with  eight  recoveries ;  Krassawsky, 
five  cases,  with  one  death ;  Frank,  six  cases,  with  one  death ;  Fehling, 
five  cases,  with  one  death ;  Tait,  seven  cases,  with  one  death ;  and  in 
the  Santa-Caterina  Hospital,  in  Milan,  ten  women  were  saved  in  thir- 
teen operations.  But  while  in  practiced  hands,  with  favorable  sur- 
roundings and  skilled  assistants,  the  results  have  been  brilliant,  all  op- 
erators have  not  been  so  fortunate.  Thus,  Dr.  R.  P.  Harris,  who  has 
with  untiring  zeal  made  all  questions  connected  with  the  Caesarean  sec- 
tion his  peculiar  province,  informs  me  that  the  number  of  operations 
performed  to  March,  1885,  in  which  the  uterus  and  its  appendages  were 
removed  after  the  extraction  of  the  child,  had  swollen  to  164  (3  mori- 
bund at  time  of  operation),  of  which  70  only  ended  in  recovery,  or  a 
little  over  43  per  cent.  In  a  late  paper  *  he  states  that  in  the  five 
years  ending  with  the  close  of  1889  there  were  reported  158  operations 
with  47  deaths,  or  a  mortality  of  29  per  cent. 

Chason,  however,  has  collected  45  cases,  reported  between  1887  and 
1889,  with  but  six  deaths,  and  in  Meyer's  f  statistics  for  1890  32  cases 
are  given,  with  five  deaths ;  an  indication  that  the  ill-success  of  the 
earlier  trials  was  due  rather  to  faulty  methods  and  to  defective  asepsis 
than  to  the  impracticable  nature  of  the  operation.  The  inferior  rank 
it  now  occupies  as  compared  Avith  the  Cesarean  section  is  not  due  to 
its  being  more  dangerous,  but  to  the  fact  that  it  involves  a  serious 
multiiation.  The  removal  of  the  uterus  and  its  appendages  as  a 
sequence  to  the  Caesarean  section  is,  however,  indicated : 

In  osteo-malacia,  owing  to  the  influence  of  ovaro-hysterectomy  in 
arresting  that  malady ;  in  uterine  atony  following  the  Sanger  Cesarean 
operation ;  in  cases  where  septic  infection  of  the  endometrium  has 
occurred  during  labor ;  in  new  formatipns  of  the  uterus,  the  removal 
of  which  is  coincidently  desired ;  in  obstruction  to  the  free  escape  of 
the  lochia  due  to  cicatricial  narrowing  of  the  parturient  canal,  and  in 
complete  rupture  of  the  uterus  with  the  passage  of  the  child  into  the 
abdominal  cavity. 

Operation. — The  preparations  and  the  details  of  the  operation  are 
the  same  as  in  Csesarean  section,  with  the  exception  of  those  which 
have  reference  to  the  ablation  of  the  uterus  and  the  prevention  of 

*  Status  of  Caesarean  Surgery,  Gyn.  Trans..  1891,  p.  120. 

f  Jahresbericht  ueber  die  Fortschritte  auf  dem  Grebiete  der  Geburtshtilfe  und 
Gynaek.,  IV  Jahrgang,  1891. 


444  OBSTETRIC  SURGERY. 

hsemorrliage.  Careful  attention  to  the  details  of  antiseptic  surgery 
is  essential  to  a  successful  issue.  In  Porro's  first  case  the  abdominal 
incision  was  nearly  five  inches  in  length.  After  opening  the  uterus 
•  and  removing  the  foetus,  the  placenta,  and  the  membranes,  Porro 
lifted  the  emptied  organ  from  the  abdomen,  and  placed  the  serre-nceud 
of  Cintrat  around  the  lower  segment,  just  above  the  os  internum. 
The  tissues  were  then  constricted  until  all  haemorrhage  from  the  cut 
uterine  surface  was  arrested.  The  uterus  was  then  cut  away  with  a 
bistoury,  the  stump  was  brought  outside  of  the  abdominal  wound,  and 
held  in  position  by  strapping  the  handle  of  the  serre-nmud  to  the  pa- 
tient's right  thigh.  Miiller  modified  Porro's  original  method  by  en- 
larging the  first  incision  upward  sufficiently  to  enable  an  assistant  to 
lift  the  uterus  outside  of  the  abdominal  walls,  and  by  applying  com- 
pression above  the  cervix  (either  the  wire  ecraseur  or  the  Esmarch 
bandage)  before  opening  the  womb  and  removing  the  child.  This 
plan  offers  the  obvious  advantage  of  rendering  the  operation  bloodless, 
and  of  making  it  easy  to  prevent  the  entrance  of  the  amniotic  fluid 
into  the  abdominal  cavity.  Breisky,  Litzmann,  Miiller,  Taruier,  and 
Elliott  Eichardson,  of  Philadelphia,  found  no  difficulty  in  tlius  draw- 
ing the  uterus  outside  the  abdominal  cavity  ;  Spaeth,  "Wasseige,  Tibone, 
Chiara,  and  Carl  Brauu,  on  the  contrary,  either  encountered  great  diffi- 
culties in  performing  the  manoeuvre,  or  were  obliged  to  abandon  it 
altogether.  According  to  Harris,  there  have  been  forty-two  Porro- 
Miiller  operations,  with  the  saving  of  twenty-one  mothers  and  thirty 
children.  The  compressors  which  have  so  far  been  employed  are  the 
Cintrat  serre-nmud,  the  chain  ecm^e^^rwith  a  Pean  attachment,  render- 
ing it  possible  after  detaching  the  chain  from  the  handle  to  maintain 
the  constriction,  the  various  forms  of  wire  ecraseur,  and  the  elastic 
ligature.  Compression  should  be  made  slowly,  and  should  not  be  car- 
ried to  the  extent  of  cutting  through  tlie  peritonteum.  Owing  to 
the'  liability  of  wire  to  break,  great  care  should  be  taken  in  its  selec- 
tion. In  case  of  accident,  a  second  instrument  should  be  held  in 
readiness. 

Fehling,  whose  excellent  record  we  have  already  noticed,  gives  the 
followmg  directions :  After  careful  disinfection  of  the  abdominal  sur- 
face, the  incision  should  be  made  in  the  median  line.  As  the  ab- 
dominal coverings  are  for  the  most  part  thin,  ligatures  are  rarely  ne- 
cessary. The  peritonaeum  should  be  divided  upon  a  grooved  director. 
Then  either  a  median  incision  is  made  through  the  uterine  walls  with 
the  uterus  in  situ  and  with  the  precautions  against  hfemorrhage  de- 
scribed in  connection  with  the  older  operation,  or,  as  recommended  by 
Miiller,  the  uterus,  after  enlarging  the  abdominal  wound,  should  be 
tilted  laterally,  and  withdrawn  outside  the  abdomen  previous  to  sec- 
tion. An  elastic  .ligature,  placed  rapidly  around  the  lower  uterine 
segment,  furnishes  a  safeguard  against  hsemorrhage.      In    the  Porro 


CESAREAN  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.    445 

operation  proper  the  elastic  ligature  is  used  after  removal  of  the  child ; 
in  the  Midler  modification,  Avhich  Fehling  prefers,  the  ligature  is  ap- 
plied previous  to  uterine  section.  In  the  latter  case  the  child  should 
be  extracted  as  speedily  as  possible,  for  the  sudden  interruption  of  the 
placental  circulation  is  decidedly  more  dangerous  to  the  child  than 
when  it  takes  place  gradually.  The  diameter  of  the  ligature  should  be 
about  one  third  of  an  inch.  After  the  removal  of  the  child  and  the 
tying  of  the  cord,  the  field  of  the  operation  should  be  cleansed  and  the 
after-birth  should  be  removed.  Feliling  next  recommends  the  apiDlica- 
tion  of  a  second  ligature  beneath  the  first.  Then  the  uterus  and  ova- 
ries are  to  be  removed,  the  stump  cauterized,  and  pins  inserted  above 
the  ligatures  to  prevent  the  recession  of  the  stump.  To  insure  the 
speedy  and  complete  union  of  the  peritoneal  surfaces  the  latter  should 
be  carefully  stitched  to  the  stump  beneath  the  ligatures.  For  this  pur- 
pose a  round  needle  and  carbolized  silk  should  be  employed.  Single 
sutures  passing  through  the  jjeritoneal  borders  and  the  uterine  tissues 
should  be  introduced  below  and  to  the  sides  of  the  stump,  and  two 
sutures  through  the  peritoneal  borders  and  uterine  tissues  upon  the 
upper  surface  of  the  stump.  Above  the  latter  two  or  three  more  sut- 
ures should  be  employed  to  bring  together  the  peritoneal  border  alone. 
The  abdominal  sutures  should  next  be  introduced,  and,  after  a  final 
cleansing  of  the  abdominal  cavity,  the  wound  shoivld  be  closed.  For  a 
dressing  Fehling  employs  iodoform,  and  fills  the  funnel-shaped  space 
around  the  remains  of  the  uterus  with  chloride-of-zinc  cotton.  Above 
he  places  iodoform  gauze  and  cotton  fixed  in  place  by  means  of  a  wide 
bandage.  The  dressing,  except  in  cases  of  bleeding  or  fever,  may  be 
left  undisturbed  for  six  to  eight  days.  The  separation  of  the  stump 
occurs  from  the  twelfth  to  the  fifteenth  day. 

Among  recent  proposed  modifications  Sutugin*  recommends,  as  a 
means  of  shortening  the  healing  process,  that,  after  the  separation  of 
the  elastic  ligature,  the  stump  should  be  first  scraped  and  pared  to  se- 
cure a  raw  surface,  and  that  then  the  borders  should  be  closed  by  liga- 
ture. For  a  day  or  two  he  leaves  in  the  lower  angle  of  the  wound  to 
secure  drainage  a  tent  of  iodoform  gauze  about  the  size  of  the  little 
finger. 

Frank  opens  the  abdomen  and  the  uterus  and  removes  the  foetus, 
then  inverts  the  uterus  and  applies  an  elastic  ligature  which  includes 
ovaries  and  cervix  outside  of  the  vagina.  The  abdominal  wound  is 
next  closed  and  the  uterus  is  amputated  below  the  ligature.  In  this 
latter  act  the  tissues  are  first  incised  down  to  the  peritonseum,  to 
which  a  separate  ligature  of  silk  is  applied.  The  recommendations  for 
this  plan  are  said  to  be  the  simplicity  of  the  technique,  the  rapidity 
with  which  the  operation  can  be  completed,  and  the  minimal  risk  of 

*  SuTUGix,  Die  Bedeutung  des  Porrosielien  Kaiserschnittes,  etc.,  Centralbl.  far 
Gynaek.,  1889,  No.  CG. 


446 


OBSTETRIC  SURGERY. 


infection,     Frank  has  operated  eiglit  times  in  the  manner  described, 
with  the  loss  of  but  one  patient.* 

The  intraperitoneal  treatment  of  the  stump,  doing  away  with  the 
dangers  arising  from  necrosis,  is  correct  in  principle,  but  up  to  the 
present  has  not  yielded  as  good  results  as  the  extraperitoneal  method. 
It  is  indicated,  however,  after  the  removal  of  myomata  imbedded  in 
the  pelvic  cavity,  and  in  cases  where  the  Porro  operation  is  employed 
for  uterine  rupture,  when,  owing  to  the  deep  seat  of  the  rent,  it  is  im- 
possible to  form  a  pedicle  of  sufficient  length  to  reach  above  the  ab- 
dominal incision. 

The  technique  necessarily  varies  with  the  conditions.  In  general 
terms  it  may  be  stated  that  the  plan  of  operation  consists  in  turning 
out  the  uterus  and  applying  a  double  series  of  ligatures  to  each  of  the 
broad  ligaments.  Between  the  median  and  outer  ligature  row  the  tis- 
sues are  then  divided  and  an  elastic  ligature  is  placed  about  the  cervix. 
After  amputation  of  the  uterus  a  wedge-shaped  portion  should  be  ex- 
cised from  the  surface  of  the  stump,  the  cervical  canal  after  thorough 
disinfection  should  be  cauterized  with  the  thermo-cautery,  deep  catgut 
sutures  should  be  introduced  to  close  the  internal  orifice  of  the  cervix, 
and  deep  and  superficial  sutures  inserted  to  approximate  the  muscular 
and  serous  surfaces  together.  After  the  removal  of  the  rubber  ligature 
the  sutures  should  be  tightened,  and  new  ones  introduced  if  oozing 
should  render  the  latter  necessary.  Bleeding  from  the  uterine  artery 
is  best  controlled,  according  to  Fritsch,  by  passing  the  central  sutures 
obliquely,  and  in  such  a  way  as  to  cross  one  another,  thereby  including 
the  vessel  between  them.  Fritsch  and  Lohlein  exsect  the  wedge  of 
tissue  from  above  downward  instead  of  in  a  transverse  direction,  so  as 
to  make  the  line  of  the  approximated  surfaces  run  parallel  to  the  ab- 
dominal incision.  Instead  of  dropping  the  stump  they  sew  its  perito- 
neal surface  to  the  abdominal  peritonaeum,  while  sutures  passed  through 
the  abdominal  walls  and  the  extremities  of  the  line  of  union  on  the 
stump  serve  to  hold  the  line  between  the  cut  surfaces  of  the  abdominal 
wound  and  above  the  peritonaeum.  Subsequent  oozing  into  the  perito- 
neal cavity  is  thus  guarded  against,  while  the  healing  is  promoted  by 
suitably  applied  aseptic  dressings.  Fritsch,  before  closing  the  abdomen, 
likewise  employs  a  stitch  to  fasten  the  severed  border  of  the  broad  liga- 
ment on  each  side  to  the  peritoneal  surface  of  the  stump. 

In  fibroids  seated  below  the  pelvic  brim  the  cavity  left  after  enucle- 
ation should  be  closed  by  a  series  of  deep  and  superficial  sutures,  or 
where  of  krge  size  a  counter-opening  should  be  made  into  the  vagina 
and  drainage  secured  below  by  means  of  iodoform  gauze,  while  the 
peritoneal  borders  of  the  capsule  are  sewed  carefully  together.  In  like 
manner  in  uterine  rupture  when  a  rent  extends  into  the  broad  liga- 
ment, the  safest  plan  seems  to  be  to  close  the  stump,  after  the  amputa- 
*  Vide  Beaucamp.  Arch.  f.  Gynack.,  vol.  xl,  p.  117. 


CESAREAN  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.    447 

tioii  of  the  intact  portion  of  the  uterus  and  trimming  of  the  torn  bor- 
der in  accordance  with  the  principles  indicated,  and  then  to  treat  the 
rent  in  the  ligament  by  a  counter-opening  into  the  vagina,  by  drainage 
below,  and  by  closure  of  the  tear  in  the  peritonaeum. 

Thomas's  Operation,  or  Laparo-Elytrotomy. — In  Professor  Thomas's 
operation,  the  dangers  of  opening  into  the  peritonaeum  and  wounding 
the  uterus  are  avoided  by  incising  the  walls  of  the  abdomen  in  the  line  of 
Poupart's  ligament,  lifting  the  peritoneeum,  and  dissecting  down  to  the 
vagina,  dividing  the  vagina  transversely,  and  then,  having  reached  the 
cervix,  extracting  the  child  through  the  passage  thus  artificially  created. 

The  credit  of  defending  the  practicability  of  the  extraperitoneal 
delivery  of  the  child  above  the  pelvic  brim  belongs  chronologically  to 
Ritgen.  It  was  the  natural  outcome  of  the  teachings  of  Abernethy 
and  Cooper,  to  whom  we  owe  the  ligation  of  the  external  iliac  artery 
without  opening  the  peritonaeum.  The  modus  operandi  was  carefully 
thought  out  by  Ritgen,  and  was  put  by  him  to  the  practical  test  Octo- 
ber 1,  1821.  The  incision  through  the  vagina,  Avhich  was  made  with 
a  sharj)  bistoury  in  a  longitudinal  direction,  was,  however,  followed  by 
such  profuse  haemorrhage  that  the  operation  was  discontinued,  and 
the  ordinary  Caesarean  section  performed  in  its  place.  The  patient 
died  at  the  end  of  fifty-eight  hours.* 

In  1823  Baudelocque  the  younger,  unaware  of  the  work  of  his 
predecessor,  advised  an  incision  down  to  the  j^eriton^eum  along  the 
external  edge  of  the  rectus  muscle,  extending  from  the  umbilicus  to 
two  inches  above  the  pubes,  separating  the  peritonaeum  from  the  iliac 
fossa  with  the  finger  introduced  into  the  lower  end  of  the  wound,  in- 
cising the  vagina  to  a  length  of  four  and  a  half  inches,  and  then  leav- 
ing the  expulsion  of  the  child  to  nature,  or  extracting  it  with  the 
short  forceps.  In  1884  he  published  an  essay  reporting  two  cases  in 
which  he  had  tried  his  plan,  modified,  however,  by  substituting  the 
flank  incision  of  Ritgen  for  that  along  the  rectus  muscle.  Like  Rit- 
gen, Baudelocque  did  not  complete  his  first  operation,  owing  to  the 
extent  of  the  vaginal  haemorrhage.  In  his  second  case  he  succeeded 
in  delivering  the  child,  which  was,  however,  dead  at  the  time  of  his 
undertaking  the  operation.  Having  accidentally  pricked  the  external 
iliac  artery,  Baudelocque  tied  the  common  iliac,  in  order  to  arrest  the 
haemorrhage  thence  resulting.  The  labor  was  likewise  complicated  by 
convulsions.  Death  took  place  on  the  fourth  day.  The  merit  of  first 
performing  laparo-elytrotomy  belongs,  therefore,  to  Baudelocque. 

In  1837  Sir  Charles  Bell,  in  his  Institutes  of  Surgery,  suggested 
practically  the  same  plan  of  procedure  as  that  subsequently  advocated 
by  Dr.  Thomas. 

*  For  the  particulars  of  this  and  the  succeeding  cases,  the  writer  is  indebted  to 
Dr.  Henry  J.  Garrigues's  model  essay  On  Gastro-Elytrotoiny,  N.  Y.  IMed.  Jour„ 
October  and  November,  1878. 


448 


OBSTETRIC  SURGERY, 


In  1870  Dr.  Thomas,  who  was  at  the  time  unaware  of  the  labors 
of  his  predecessors,  read  a  memorable  paper  before  the  Medical  Asso- 
ciation of  Yonkers,  giving  an  account  of,  first,  laparo-elytrotomy  per- 
formed tentatively  upon  the  cadaver  of  a  woman  dying  in  the  ninth 
month  of  pregnancy ;  and,  second,  upon  a  living  woman  at  the  end  of 
the  seventh  month  of  pregnancy,  who  had  been  suffering  from  pneu- 
monia for  a  week  or  ten  days,  and  was  at  the  time  of  his  visit  171  ar- 
ticulo  mortis.  The  operation  was  undertaken  in  the  interest  of  the 
child,  which  Wcis  extracted  alive,  and  survived  about  an  hour.  In 
1874  the  operation  was  repeated  by  Dr.  Skene.  The  patient  had  been 
forty-eight  hours  in  labor,  and  unsuccessful  attempts  at  delivering  her 
by  craniotomy  had  been  resorted  to.  She  was  suffering  at  the  time  of 
the  operation  from  exhaustion  and  shock,  which  gradually  became 
more  marked,  and  she  died  seven  hours  after.  In  1875  and  in  1877 
Dr.  Skene  had  the  glory  of  successfully  performing  the  operation 
under  circumstances  of  great  difficulty,  with  the  result  in  each  case  of 
saving  the  lives  of  both  mother  and  child.  In  1877  Dr.  Thomas  had 
the  good  fortune  to  obtain  a  like  triumph.  In  England  the  operation 
has  been  performed  by  Drs.  Himes  and  Edes,  both  times  in  the  inter- 
est of  the  child,  the  condition  of  the  mothers  being  well-nigh  hopeless. 
Both  children  were  saved.  In  1880  Dr.  "Walter  R.  Gillette  *  extracted 
by  laparo-elytrotomy  a  putrid  child,  which  he  was  obliged  to  perforate 
and  extract  with  the  cephalotribe,  the  forceps  and  version  having  been 
previously  tried  without  success.  The  mother  recovered  with  scarcely 
an  untoward  symptom. 

Itt  1883  Professor  W.  H.  Taylor,  of  Cincinnati,  operated  with  a 
fatal  result.  Forceps,  craniotomy,  the  cranioclast,  and  version  had 
been  previously  tried  in  vain.  When  laparo-elytrotomy  was  decided 
upon,  the  patient  was  much  exhausted,  with  a  very  rapid,  feeble  pulse 
and  elevated  temperature.  The  patient  died  forty-four  hours  after 
the  operation.  In  the  same  year  Professor  Jewett,  of  Brooklyn,  oper- 
ated upon  a  patient  who  had  been  a  Aveek  in  labor.  The  woman  was 
exhausted  by  long  labor,  and  previous  attempts  at  replacing  the  arm, 
by  the  use  of  forceps  and  by  attempts  at  version.  The  uterus  was  in  a 
state  of  tonic  contraction,  and  the  soft  parts  were  excessively  cedema- 
tous.  The  child  died  before  delivery.  The  mother  died  seventy  hours 
later  of  acute  septicaemia. 

In  the  year  1885  Drs.  Skene  and  Jewett  operated  each  successfully, 
and  since  then  an  additional  successful  case  has  been  reported  by  Dr. 
McKim.  The  statistical  results,  therefore,  of  laparo-elytrotomy  are 
the  saving  of  seven  mothers  in  thirteen  operations.  But  in  no  one  of 
the  fatal  cases  were  tlie  conditions  such  as  to  render  success  a  possi- 
bility. 

*  Gillette,  A  Successful  Case  of  Laparo-Elytrotoiny,  Am.  Jour,  of  Obstet., 
January,  1S80,  p.  98, 


CESAREAN  SECTION.— OPERATIONS  OP  THOxMAS  AND  PORRO.    449 

The  vaginal  haemorrhage  noted  in  the  cases  of  Ritgen  and  Baude- 
locque  can  apparently  be  avoided  by  tearing  the  vagina  transversely, 
as  recommended  by  Thomas,  in  place  of  incising  it  with  a  bistoury.  In 
four  of  the  cases  vesico-vaginal  fistulse  were  produced,  but  all  healed 
spontaneously.  The  following  description  of  the  operation  is  bor- 
rowed from  the  excellent  essay  of  Dr.  Garrigues,  which  has  already 
been  quoted.  It  has  received  the  sanction  of  Drs.  Thomas,  Skene,  and 
Gillette,  with  the  exception  that,  in  discussion,  all  have  agreed  that  it 
is  desirable  to  insert  a  perforated  drainage-tube  through  the  abdomi- 
nal wound  into  the  vagina,  and  to  keep  the  parts  cleansed  with  anti- 
septic injections. 

Operation. — "  The  bowels  having  been  emptied  by  an  aperient  and 
a  copious  enema,  and  the  os  having  been  fully  dilated  by  Barnes's  water- 
bags,  if  it  is  not  so  already,  the  patient  is  placed  on  her  back,  on  a 
long,  narrow  table  covered  with  a  mattress  or  quilts,  rubber  or  oil- 
cloth, and  a  sheet.  The  pelvis  is  well  elevated  on  a  hard  cushion,  the 
head  and  shoulders  slightly  raised  by  means  of  pillows,  the  legs  stretched 
out.  If,  from  some  cause,  it  has  been  impossible  to  dilate  the  os  fully 
by  Barnes's  dilators,  it  is  now  done  by  the  fingers,  or  if  that  is  impossi- 
ble too,  it  is  dilated  later  through  the  abdominal  wound.  The  patient 
is  anaesthetized.  Since  disinfection  can  not  be  carried  out  strictly, 
and  since  its  administration  would  give  some  additional  trouble,  it  is 
scarcely  necessary  to  operate  under  disinfectant  spray. 

"  The  operator  takes  his  place  at  the  right  side  of  the  patient.  Be- 
sides one  who  administers  the  anaesthetic,  four  assistants  are  needed — 
one  on  either  side  of  the  operator,  and  two  in  front  of  him.  The  first 
assistant,  standing  at  the  left  of  the  patient's  chest,  kys  his  flat  hands 
under  the  umbilicus  and  draws  the  uterus  upward  and  toward  the 
left,  thereby  putting  the  skin  in  the  right  iliac  region  on  the  stretch. 
Counter-extension  may  be  made  by  the  assistant  placed  at  the  right  of 
the  operator.  A  slightly  curved  incision  is  made  through  the  skin 
from  a  point  one  inch  and  three  quarters  (4-5  centimetres)  above  and 
outside  the  spine  of  the  pubes,  parallel  to  and  an  inch  above  Pou- 
part's  ligament,  to  a  point  an  inch  above  the  anterior  superior  spine 
of  the  ilium.  This  incision  may  also  be  made  in  the  opposite  direc- 
tion, from  without  inward.  By  a  few  touches  with  the  edge  of  the 
knife  the  external  oblique  muscle  is  laid  bare,  and  spouting  branches 
of  the  superficial  epigastric  artery  secured  by  holding-forceps.  The 
abdominal  muscles  are  cut  to  the  same  extent,  layer  by  layer,  the  ex- 
ternal oblique,  the  internal  oblique,  and  the  transversalis,  the  first  of 
which  is  aponeurotic.  The  transversalis  fascia  is  very  carefully  hooked 
up  with  a  fine  tenaculum,  and  the  knife  carried  horizontally,  so  as  to 
make  a  small  opening  in  it,  avoiding  the  peritonaeum  that  lies  be- 
neath it,  separated  from  it  by  loose  areolar  tissue,  and  sometimes  fat. 
A  director  is  introduced  through  the  opening  and  pushed  between  the 
29 


^5Q  OBSTETRIC  SURGERY. 

fascia  and  the  peritonieum  toward  the  inner  and  the  onter  angle  of 
the  wound,  and  the  fascia  is  cut.  The  best  instrument  for  this  pur- 
pose is  Key's  hernia  director,  the  one  which  Spencer  AVells  uses  when 
incising  the  peritonaeum  in  ovariotomy.  It  is  firm,  a  quarter  of  an 
inch  (six  millimetres)  broad,  slightly  curved  on  the  fiat,  well  rounded 
at  the  end,  and  has  on  its  concave  side  a  groove  that  stops  a  quarter 
of  an  inch  (six  millimetres)  from  the  point  of  the  instrument.  Next, 
the  operator  places  the  pulp  of  his  fingers  on  the  peritonaeum,  separat- 
ing it  from  the  transversalis  and  iliac  fascia,  until  he  reaches  the  vagi- 
na! wall.  The  second  assistant,  placed  at  the  left  of  the  operator, 
holds  the  peritoneum  and  intestines,  applying  a  fine,  warm  napkin 
under  his  hands,  in  order  to  be  sure  not  to  let  them  slip.  The  first 
assistant  draws  the  uterus  vigorously  upward  and  toward  the  left,  in 
order  to  expose  the  deeper  part  of  the  vaginal  wall  on  the  right  side. 
A  female  silver  catheter  is  introduced  into  the  bladder  by  the  third 
assistant,  placed  at  the  left  hip  of  the  patient  and  held  in  the  known 
direction  of  the  boundary-line  between  the  bladder  and  the  vagina, 
below  the  ureter  on  the  side  on  which  the  operation  is  being  per- 
formed. A  blunt  woollen  instrument,  something  like  the  obturator 
of  a  cylindrical  speculum,  only  longer,  is  introduced  into  the  vagina 
and  applied  above  the  linea  ileo-pectinea,  raising  the  vaginal  wall  as 
much  as  possible  into  the  abdominal  wound.  An  incision  is  made 
parallel  to  the  ileo-pectineal  line  and  the  catheter  felt  in  the  bladder, 
as  far  below  the  uterus  as  possible,  in  order  to  avoid  the  ureter  and 
Douglas's  pouch,  and  incise  where  there  are  fewest  vessels,  cutting 
down  on  the  obturator  witli  Paquelin's  thermo-cautery,  the  galvano- 
caustic  knife,  or  simply  cautery-irons  (table-knives)  only  heated  to 
red  heat.  The  surrounding  parts  are  protected  by  the  application  of 
wet  compresses  around  the  place  to  be  cauterized.  The  incision  made 
by  the  cautery  is  extended  forward  toward  the  symphysis  and  back- 
ward toward  the  promontory  by  placing  the  pulp  of  both  index-fin- 
gers perpendicularly  on  the  edges,  and  api^lying  the  force  in  different 
places  in  the  direction  of  the  os  uteri  and  the  ileo-pectineal  line,  so  as 
to  tear  the  vaginal  wall  as  far  forward  as  is  deemed  safe  in  regard  to 
the  bladder  and  the  urethra,  the  locality  of  which  organs  is  ascertained 
by  feeling  the  catheter  held  by  the  assistant,  and  as  far  backward  as 
the  wound  in  the  abdomen  will  allow.  Now  the  catheter  is  withdrawn, 
the  membranes  ruptured  if  the  liquor  amnii  has  not  escaped  before, 
the  uterus  tilted  as  much  as  possible  to  the  opposite  side,  and  the  os 
drawn  with  the  forefinger  into  the  iliac  fossa. 

"  The  operator  draws  the  child  through  the  double  Avound  either  by 
simple  extraction,  or  after  turning,  or  by  applying  the  forceps,  accord- 
ing to  the  presentation  and  other  particular  circumstances.  The  pla- 
centa is  expelled  by  compressing  the  uterus,  and  withdrawn  through 
the  wound. 


CESAREAN  SECTION.— OPERATIONS  OF  THOMAS  AND  PORRO.    451 

"  If  bleeding  occurs,  the  operator  tries  to  check  it  by  applying  liga- 
tures through  the  abdominal  wound,  holding-forceps,  styptics,  or  cau- 
teries, using  a  large  wooden  tubular  sjjeculum ;  or  a  Sims  speculum 
may,  perhaps,  give  easier  access  to  the  bleeding  vessel  than  anything 
else.  If  it  be  impossible  to  check  the  haemorrhage,  the  vaginal  wound 
must  be  firmly  tamponed  from  below  through  the  rulva  and  from  the 
abdominal  wound  with  cotten  pledgets  soaked  in  cold  water  and 
squeezed,  and  held  in  siiu  by  broad  straps  of  adhesive  plaster  round 
the  abdomen,  as  after  ovariotomy.  Except  in  the  last  eventuality,  the 
bladder  is  distended  by  injecting  lukewarm  milk  in  order  to  ascertain 
if  this  organ  has  been  injured.  If  so,  the  fistula  is  immediately  sewed 
with  catgut,  which  need  not  be  removed.  The  wound  is  cleaned  by 
injecting  a  stream  of  lukewarm  carbolized  water  (two  per  cent),  or  a 
solution  of  thymol  (two  per  thousand),  from  the  vagina  and  from  the 
abdominal  wound.  Next,  the  edges  of  the  abdominal  wound  are 
brought  together  by  interrupted  sutures,  and  the  lower  part  of  the 
abdomen  covered  with  borated  or  sali(?ylated  cotton,  and  surrounded 
by  broad  straps  of  adhesive  plaster  fastened  to  the  hips,  as  in  ovari- 
otomy. A  jaledget  of  cotton  soaked  in  carbolized  oil  (1  to  10)  is  applied 
at  the  entrance  of  the  vagina." 

Professor  William  M.  Polk  has  demonstrated  that  the  operation  can 
be  performed  as  well  upon  the  left  side  as  upon  the  right.* 

*  Polk,  N.  Y.  Med.  Jour.,  May,  1883. 


THE   PATHOLOGY   OF   LABOR 


CHAPTER  XXIV. 

ANOMALIES  OF  THE  EXPELLENT  FORCES. 

Precipitate  labors— Tardy  labors.— Irregular  paitis  in  the  first  stage  of  labor.— 
Treatment  of  protracted  first  stage.— Irregular  pains  in  the  second  stage.— 
Treatment  of  protracted  second  stage.— On  the  use  of  ergot  in  labor.— Irregu- 
lar pains  in  the  third  stage ;  treatment.- Painful  labors :  from  hysteria ;  from 
rheumatism ;  from  intestinal  irrjtation ;  from  inflammatory  changes. 

I]sr  physiological  labor  the  expelleiit  forces  are  adequate  to  over- 
come the  resistance  encouuterecl.  Labor  becomes  pathological — 1. 
When  the  pains  are  defective ;  2.  When  the  resistance  offered  by  the 
soft  parts  or  the  bony  pelvis  exceeds  the  limits  of  safety  to  the  mother 
or  the  child ;  3.  When  natural  delivery  is  rendered  difficult  or  impos- 
sible, owing  to  malformations  or  malpresentations  of  the  fa?tus ;  4.  In 
consequence  of  dangerous  complications,  sucli  as  haemorrhage,  eclamp- 
sia, and  prolapsed  funis. 

From  a  clinical  j^oint  of  view  the  anomalies  of  the  labor-pains  are 
divisible  into  pains  in  excess,  weak  pains,  pains  attended  by  an  extreme 
of  physical  suffering,  and  pains  complicated  by  strictures.  Physiologi- 
cally, however,  these  different  forms  are  far  from  composing  distinct 
conditions,  isolated  from  one  another.  Thus,  rigidity  of  the  os  is  always 
intensely  painful,  and  is  usually  dependent  upon  feeble  action  of  the 
expellent  forces.  There  is  no  standard  of  strength  by  which  the  weak- 
ness or  excess  of  pains  can  be  measured.  The  terms  are  always  rela- 
tive, and  are  used  with  reference  to  the  obstacles  to  be  overcome.  In 
primiparse  strong  pains  are  requisite  to  induce  softening  and  dilata- 
tion of  the  cervix.  In  multiparse  pains  may  be  intrinsically  weak,  and 
yet  suffice  to  bring  labor  to  a  prosperous  conclusion.  Much  confusion 
of  mind  is  often  occasioned  by  the  double  sense  in  which  the  term 
"labor-pains"  is  employed.  Thus,  it  is  frequently  stated  that  the 
pains  are  good,  when  an  examination  reveals  only  a  feeble  measure  of 
expellent  force,  the  word  "  pains  "  representing  nothing  more  than  an 
acute  degree  of  physical  suffering.  Clinically,  pains  are  to  be  judged 
by  the  effects  they  produce.  In  practice  it  will  be  found  convenient 
to  study  the  various  forms  of  irregular  uterine  action  in  connection 


ANOMALIES   OF   THE   EXPELLENT   FORCES.  453 

with  the  results  of  their  influence  upon  the  duration  of  labor.  These 
results  are — 1.  Precipitate  labor ;  2.  Tardy  labor. 

Precipitate  Labors. — It  is  customary  to  ascribe  precipitate  labors  to 
an  excess  of  the  pains.  The  term  excess  is,  however,  only  relative. 
There  is  no  reason  to  believe  that  the  uterus  ever  acts  with  such  a 
degree  of  energy  a.s  per  se  to  constitute  a  pathological  condition.  With 
a  large,  roomy  pelvis,  a  soft,  dilatable  cervix,  a  distensible  vagina  and 
perinffium,  labor  may  be  terminated  by  a  few  strong  pains.  Such 
rapid  deliveries  are  not  to  be  regarded  with  apprehension.  As  a  rule, 
they  are  followed  by  firm  retraction  of  the  uterus,  and  the  continu- 
ance of  good  contractions  acts  as  a  safeguard  against  haemorrhage. 
The  puerperal  state  usually  pursues  a  favorable  course.  Aside  from 
the  inconvenience  which  sometimes  results  when,  perchance,  women 
are  suddenly  overtaken  by  labor-pains  in  the  streets  or  in  public  places, 
an  easy,  rapid  labor  is  to  be  regarded  as  one  of  the  varieties  of  normal 
labor.  Except  the  adoption  of  jirecautions  against  such  untoward 
accidents,  they  call  for  no  special  treatment. 

When,  however,  the  parturient  act  occurs  in  women  who  possess 
an  undue  reflex  irritability,  which  impels  them  to  an  excessive  use  of 
the  abdominal  muscles,  it  is  possible  for  serious  mischief  to  ensue. 
Thus,  if  the  patient  happens  to  be  seized  when  in  the  standing  posture, 
the  straining  efforts  may  throw  the  child  suddenly  upon  the  floor ;  but 
even  here  the  consequences  are  less  detrimental  than  would  be  natu- 
rally anticipated.  The  force  of  the  fall  is  usually  broken  by  the  cord. 
Lacerations  of  the  latter  take  place  at  a  distance  from  the  navel,  and 
are  not  followed  by  haemorrhage.  Post-partum  haemorrhage,  prolapse, 
and  inversion  of  the  uterus  are  said  to  be  possible  occurrences,  though 
of  extreme  infrequency.  When  all  the  exiaellent  forces  are  called  into 
play  at  an  early  period  of  labor,  before  the  rigidity  of  the  utero-vaginal 
canal  has  been  overcome,  the  violent  straining  has  been  known  to  cause 
subcutaneous  emphysema  of  the  head  and  neck,  to  interfere  Avith  the 
utero-placental  circulation,  and  even  to  produce  fracture  of  the  fetal 
skull.  Excessive  straining  before  the  soft  parts  have  been  properly 
prepared  for  the  passage  of  the  child  may  likewise  lead  to  lacerations 
of  the  cervix,  vagina,  and  perinseum. 

The  proper  treatment  for  this  condition  is  to  lower  the  reflex  irri- 
tability by  hypodermic  injections  of  morphia ;  or,  better  still,  by  the 
production  of  complete  anaesthesia,  so  as  to  susjoend  the  action  of  the 
voluntary  muscles. 

Tardy  Labors. — For  the  proper  understanding  of  labors  protracted 
beyond  the  period  of  safety  by  irregular  uterine  contractions,  it  is 
necessary  to  bear  in  mind  the  principal  features  of  normal  delivery. 
These  are,  contractions  of  the  uterus  followed  by  relaxation  and  dis- 
tinct periods  of  repose ;  stretching  and  thining  of  the  muscular  fibers 
below  the  contraction  ring,  with  retraction  of  the  uterus  above  that 


454  THE   PATHOLOGY  OP  LABOR. 

point ;  softening  and  dilatation  of  the  cervix ;  the  fixation  of  the  uterus 
in  the  axis  of  the  pelvis ;  and  the  addition  of  the  abdominal  muscles  to 
the  expellent  forces. 

The  first  requisite  of  every  normal  labor  is  that  the  pains  shall  be 
good — i.  e.,  shall  possess  a  markedly  expulsive  character.  We  have 
seen  that  for  the  uterus  to  perform  work  the  contractions  should  not 
be  continuous,  but  distinctly  rhythmical.  For  effective  work,  more- 
over, the  excursions  of  the  uterus  during  a  contraction  should  possess  a 
certain  degree  of  amplitude,  and  the  interval  between  the  contractions 
should  be  sufficient  to  allow  the  nervous  system  to  recover  from  the 
shock  of  pain. 

Irregular  Pains  in  the  First  Stage  of  Labor. — In  the  first  stage  of 
labor  pains  are  most  frequently  defective  by  reason  of  their  short  dura- 
tion. As  a  rule,  short,  cramp-like  pains  occasion  acute  suffering. 
When  they  recur  with  little  or  no  interval  between  them,  they  are  very 
exhausting  to  the  patient.  As  the  cervix  in  such  cases  is  tense  and 
rigid,  it  is  to  this  condition  that  the  delay  is  usually  attributed.  If, 
however,  the  tissues  of  the  cervix  are  liealtliy,  the  presentation  is  nor- 
mal, and  the  pains  preserve  their  expulsive  character,  rigidity  of  the 
cervix  is  never  an  obstacle  to  delivery.  The  activity  of  the  organic 
changes  which  lead  to  softening  and  dilatation  is  closely  related  to  tlie 
activity  of  the  uterine  contractions.  The  exception  to  this  rule  in  pri- 
miparae  is  only  apparent.  To  be  sure,  in  them  the  firm,  closely  knitted 
tissues  of  the  cervix  yield  more  gradually  to  the  dilating  forces  than 
in  multipara.  Indeed,  in  multii3ara3  we  sometimes  find  the  organic 
changes  in  the  cervix  induced  by  contractions  which  liave  hardly  ex- 
cited the  notice  of  the  woman ;  but  in  primiparae,  while  good  pains, 
under  the  reservations  mentioned,  certainly  induce  softening  of  the 
cervix,  weak  pains  effect  no  changes  in  its  tissues. 

The  uterine  contractions  may  be  abnormal  from  the  commence- 
ment of  labor ;  more  frequently  the  loss  of  their  expulsive  character  is 
a  secondary  condition.  In  many  primiparous  women  labor  progresses 
in  an  auspicious  manner  for  a  time,  inspiring  hopes  of  a  speedy  ter- 
mination. Then  the  cervix,  which  had  previously  been  dilating  favor- 
ably, becomes  rigid,  the  sufferings  of  the  patient  during  each  contrac- 
tion are  enhanced,  and  further  advance  is  arrested.  This  transforma- 
tion is  not  to  be  accounted  for  by  a  spasm  of  the  circular  fibers  of  the 
OS,  but  is  the  result  of  secondary  changes  in  tlie  action  of  the  uterus 
itself.  The  right  understanding  of  the  phenomenon  in  question  ren- 
ders it  necessary  to  recall  the  physiological  fact  that  the  uterus  is 
endowed  not  only  with  contractility,  but  with  retractile  properties 
likewise.  These  are  shown  in  a  marked  way  by  the  manner  in  which 
the  uterus  closes  upon  its  contents  after  the  escape  of  the  amniotic 
fluid ;  so,  too,  by  the  manner  in  which  the  uterus  follows  down  the 
foetus  during  the  period  of  expulsion.     Normally,  the  gradual  closure 


ANOMALIES  OP  THE  EXPELLENT   FORCES.  455 

of  the  uterus  upon  the  ovum  leads  with  a  dilated  os  to  the  permanent 
formation  of  the  bag  of  waters.  Thus  it  will  be  seen  that  in  normal 
labor  retractility  is  a  wholly  beneficent  possession  of  the  uterus.  When, 
however,  from  any  cause  the  cervix  dilates  slowly,  and  the  pains  are 
strong  and  close  together,  as  the  uterus  retracts  upon  the  stationary 
ovum,  the  excursions  made  by  the  labor-pains  shorten,  which  thus  tend 
to  assume  the  clonic  form.  The  continuance  of  the  same  process  leads 
finally  to  the  close  investment  of  the  ovum  by  the  uterus,  when  the 
only  indication  of  contractility  which  remains  is  the  increased  harden- 
ing of  the  uterus  at  short  intervals.  These  changes  in  the  character  of 
the  contractions  are  marked  by  corresponding  changes  in  the  cervix, 
the  condition  of  the  latter  affording  an  index  of  that  of  the  entire 
uterus  in  much  the  same  way  that  a  furred  tongue  bespeaks  a  catarrhal 
condition  of  the  stomach. 

These  secondary  changes  in  the  pains  are  dependent  upon  a  variety 
of  conditions.  The  tardy  dilatation  of  the  cervix,  which  stands  in  a 
causal  relation  to  them,  may  result  from  overdistention  of  the  mem- 
branes Avith  amniotic  fluid,  or  from  their  firm  adhesion  to  the  walls  of 
the  uterus  around  the  os  internum — conditions  which,  in  either  case, 
interfere  with  the  stretching  of  the  lower  segment,  and  thus  lead  to 
waste  of  uterine  force  by  distributing  it  uniformly  over  the  entire 
ovum.  Again,  where  there  is  lack  of  parallelism  between  the  axis  of 
the  uterus  and  that  of  the  pelvic  brim,  the  presenting  part  may,  by 
bearing  especially  upon  the  anterior  portion  of  the  lower  uterine  seg- 
ment and  of  the  cervix,  exercise  so  little  jn-essure  upon  the  os  that  its 
sphincter  long  maintains  its  integrity.  Finally,  irregular  contractions 
may  be  consequent  upon  faulty  presentations,  and  upon  any  form  of 
pelvic  obstruction. 

A  special  and  dangerous  form  of  irregularity  results  when  the  mem- 
branes rupture  prematurely,  and  the  entire  amount  of  amniotic  fluid 
leaks  away.  This,  to  be  sure,  is  a  rare  event,  as  the  presenting  part,  as 
a  rule,  acts  as  a  valve  which  closes  the  lower  segment  of  the  uterus, 
and  prevents  the  amniotic  fluid  from  escaping.  When,  however,  ow- 
ing to  the  small  size,  the  uneven  shape,  or  the  hindered  descent  of  the 
presenting  part,  the  accident  in  question  takes  place,  as  a  combined 
result  of  muscular  retractility  and  the  pressure  of  the  intestines  dur- 
ing the  pains,  the  uterus  gradually  conforms  to  the  surface  of  the 
fcetus.  In  this  way  the  much-dreaded  "  dry  labors  "  are  produced. 
The  consequences  are  far-reaching.  The  retraction  of  the  muscular 
fibers  about  the  child's  neck  in  head  presentations  forms  an  impedi- 
ment to  natural  delivery;  the  disturbance  of  the  utero-placental  cir- 
culation endangers  the  life  of  the  child ;  the  uterine  walls  applied  to 
the  convex  surfaces  of  the  child  become  ana?mic,  Avhile  the  re-entrant 
portions,  subjected  to  negative  pressure,  become  hyperaemic  and  oedem- 
atous,  extravasations  take  place  into  the  tissues,  the  walls  are  rendered 


456  THE  PATHOLOGY   OF  LABOR. 

friable,  the  contractions  are  associated  with  intense  pain,  and  peritoneal 
irritability  develops.* 

The  prolonged  retraction  of  the  uterus  may  be  followed  in  the  end 
by  the  entire  cessation  of  pains,  and  paralysis  may  ensue.  Uterine 
retractility  is  not  precisely  the  same  force  as  that  which  causes  the 
expulsion^  of  a  fluid  from  an  overdistended  elastic  sac,  for  retractil- 
ity and  contractility  are  in  the  uterus  rarely  disassociated  from  one 
another.  When  the  uterus  ceases  to  contract,  it  forfeits,  as  a  rule, 
its  retractile  properties  likewise,  f  It  sometimes  follows,  therefore, 
that,  following  prolonged  tonic  contraction,  after  the  evacuation  of 
the  uterus,  the  walls  of  the  latter  collapse  like  those  of  a  pricked 
bladder. 

The  Treatment  of  a  Protracted  First  Stage.— The  treatment  of  a 
protracted  first  stage  has  for  its  object  the  mitigation  of  pain  and  the 
restoration  of  their  expulsive  quality  to  the  uterine  contractions.  No 
plan  of  action  should  be  decided  upon  without  first  carefully  investi- 
gating the  cause  of  delay.  The  suspensive  influence  of  a  full  bladder 
or  rectum  is  always  to  be  borne  in  mind.  In  face,  breech,  and  shoul- 
der presentations,  and  in  contracted  pelves,  the  slow  dilatation  of  the 
cervix  is  the  rule,  and,  with  such  exceptions  as  will  be  noted  in  their 
appropriate  connections,  do  not  call  for  interference.  A  faulty  posi- 
tion of  the  uterus  should,  if  possible,  be  rectified  by  suitable  abdom- 
inal support.  Adhesions  of  the  membranes  to  the  lower  uterine  seg- 
ment should  be  dissected  up  by  the  index-finger.  In  hydramnion, 
rupture  of  the  membranes,  so  as  to  allow  the  partial  escape  of  the  am- 
niotic fluid,  is  sometimes  serviceable. 

If  the  length  of  the  labor  is  simply  due  to  the  insuflftcient  uterine 
action,  the  conduct  of  the  accoucheur  will,  in  a  measure,  depend  upon 
the  frequency  and  severity  of  the  pains  and  the  endurance  of  the 
patient.  If  the  pains  occur  at  such  intervals  and  with  such  mildness 
that  the  patient  is  able  to  eat,  to  sleep,  and  to  attend  to  ordinary 
household  duties,  the  dilatory  progress  of  labor  should  cause  no  appre- 
hension. In  pathological  conditions  it  is  the  element  of  pain  which 
is  most  to  be  dreaded.  Pain  long  continued  is  a  powerful  nerve-de- 
pressant When  combined  with  starvation  and  deprivation  of  sleep, 
it  greatly  impairs  a  woman's  capacity  to  resist  the  perils  of  the  pucr 
peral  period.  While,  therefore,  the  indication  for  treatment  is  clear 
enough,  it  is  not  so  easy  in  a  given  case  to  decide  whether  the  remedy 
should  be  applied  first  to  the  relief  of  pain,  or  whether  efforts  should 
be  directed  at  once  to  the  acceleration  of  labor,  so  as  most  speedily  to 
place  the  patient  beyond  the  hazards  of  parturition.  As  a  rule,  how- 
ever, it  may  be  stated  that  anodynes  are  appropriate  in  cases  where  the 

*  Lahs,  Die  Theorie  der  Geburt,  pp.  285  et  seq. 

t  Breisky,  Ueber  die  Beh.imllwng  der  puerperalen  Blutungen,  Volkinann's 
Samml.  klin.  Vortr.,  No.  14.  p.  93. 


ANOMALIES  OF  THE  EXPELLENT  FORCES.  45Y 

cervix  is  but  slightly  dilated,  while  accelerative  measures  naturally  re- 
ceive the  preference  in  those  where  the  first  stage  of  labor  is  already 
far  advanced. 

The  pain-stilling  agents  from  which  the  selection  should  be  made 
are  the  warm  bath,  chloroform,  chloral  by  rectal  injection,  and  mor- 
phine, either  alone  or  combined  with  minute  doses  of  atropine.  In  prac- 
tice it  will  usually  be  found  convenient  to  begin  with  chloroform,  and 
then  to  sustain  its  action  by  the  hypodermic  injection  of  morphine,  or 
the  rectal  administration  of  chloral,  suspending  the  chloroform  so  soon 
as  the  tranquillizing  effect  of  the  latter  is  developed.  Anodynes  often 
accomplish  wonders  in  one  of  two  ways :  when,  owing  to  the  prolonga- 
tion of  the  labor  and  its  attendant  pain,  the  patient's  nervous  energies 
have  become  exhausted,  the  arrest  of  pain  enables  the  woman  to  sleep, 
and,  with  the  recuperation  of  power  that  comes  upon  awakening,  good 
pains  follow,  which  bring  the  labor  to  a  happy  termination.  In  other 
cases,  after  the  employment  of  the  anodyne  the  parts  apparently  relax, 
and  an  acceleration  of  labor  follows.  In  these  cases  the  oxytocic  effect 
is  probably  due  to  the  quieting  action  exerted  upon  the  spinal  nerves. 
It  has  been  surmised  that  the  nerves  of  the  uterus  derived  from  the 
cerebro-spinal  system  possess  inhibitory  properties — a  theory  which, 
if  true,  readily  explains  how  severe  pain  suspends  uterine  action,  and 
how  the  quieting  of  pain  would  restore  to  the  motor  nerves  their  full 
energy. 

In  a  certain  proportion  of  cases  the  effects  of  the  anodyne  or  an- 
aesthetic are  of  but  short  duration.  In  from  ten  to  thirty  minutes  the 
acute  suffering  returns,  and  the  short  truce  is  unattended  with  benefit. 
There  is  an  erroneous  opinion  that,  so  long  as  the  membranes  are  un- 
ruptured, this  condition  may  be  allowed  to  go  on  indefinitely.  It  is, 
however,  of  the  greatest  importance  that  the  length  of  the  period  of 
non-interference  should  be  governed  by  the  strength  of  the  patient. 
There  is  nothing  that  requires  more  judgment  in  midwifery  practice 
than  to  decide  when  the  time  has  arrived  at  which  delay  is  fraught 
with  more  danger  than  active  interference.  For  my  own  part,  I  be- 
lieve that  many  fair  lives  are  needlessly  squandered  because  of  excess- 
ive timidity  begotten  of  imperfect  obstetric  teachings. 

If  iDain-stilling  agents  do  no  good,  or  if  the  first  stage  is  already 
far  advanced,  the  physician  should  seek,  by  restoring  to  the  pains  their 
expulsive  character,  to  hasten  delivery. 

Of  reputed  service  in  cases  of  uterine  insufficiency  are  the  warm 
vaginal  douche,  the  dilating  bags  of  Barnes,  the  introduction  of  a 
bougie  into  the  uterus,  forceps,  and  the  internal  administration  of 
quinine,  ergot,  viscum  album,  borax,  cannabis  Indica,  cinnamon,  or 
digitalis. 

The  bougie  is  applicable  only  to  cases  where  the  membranes  are 
intact,  and  where  the  pains  are  weak  without  being  cramp-like  in  char- 


458  THE   PATHOLOGY  OF  LABOR. 

acter.  It  should  in  all  cases  be  surgically  clean,  as  otherwise  it  can  be- 
come the  carrier  of  infection  to  the  uterine  cavity. 

The  vaginal  douche  possesses  a  wider  range  of  utility.  It  is  safe 
and  tolerably  effective  under  favorable  conditions.  It  promotes  the 
organic  changes  in  the  cervix,  stimulates  the  uterus  to  contract,  and 
mechanically  distends  the  vagina.  Its  action  is,  however,  apt  to  be 
slow  and  somewhat  uncertain.  In  a  case  of  overdistention  of  the 
amnion,  I  once  saw  its  employment  followed  immediately  by  complete 
tonic  rigidity  of  the  uterine  muscular  fibers. 

Of  all  the  resources  at  our  disposal,  however,  the  water-bags  of  Dr. 
Barnes  stand  easily  at  the  head.  Passed  within  the  cervix,  and  dis- 
tended so  as  to  place  the  canal  moderately  upon  the  stretch,  they  not 
only  serve  to  mechanically  dilate  the  os,  but  are  most  efficient  as  reflex 
exciters  of  the  labor-pains.  If  left  in  situ  until  expelled  into  the  vagi- 
na by  the  bearing-down  efforts  they  awaken,  the  cervix  will  be  found 
to  have  lost  its  rigidity.  If  necessary,  a  larger  dilating-bag  should 
then  be  employed  in  the  same  way.  An  attempt  to  dilate  the  cervix 
rapidly  and  with  violence  is  neither  safe  nor  profitable.  To  obtain 
permanent  results  it  is  essential  to  effect  the  organic  changes  in  the 
tissues  which  render  them  physiologically  dilatable.  In  cases  of  tonic 
rigidity  of  the  uterus,  the  production  of  normal  pains  will  sometimes 
be  assisted  by  rupturing  the  membranes  and  raising  the  head,  so  as  to 
allow  a  small  portion  of  the  amniotic  fluid  to  escajio,  previous  to  re- 
sorting to  the  Barnes  water-bags. 

When,  after  rupture  of  the  membranes,  a  segment  of  the  head  pre- 
sents at  the  OS  externum,  the  rubber  bags  are  of  less  service.  In  such 
cases  often  we  are  able  to  accomplish  speedy  dilatation  by  simply  ask- 
ing the  woman  to  hold  her  breath,  and  to  re-enforce  the  uterine  pains 
by  the  action  of  the  auxiliary  muscles.  If  this  plan  fails,  forceps 
should  be  applied,  and  the  head  be  made  to  serve  as  the  dilating  body. 
To  avoid  lacerating  the  cervix,  the  tractions  should  be  intermittent, 
and  should  be  suspended  during  the  acme  of  the  pains.  The  rule 
given  for  the  preservation  of  the  perinaeum  will  be  found  most  service- 
able in  attempts  to  maintain  the  integrity  of  the  cervix,  viz.,  that  the 
extraction  is  most  safely  accomplished  during  the  period  of  greatest 
relaxation,  and  not  at  the  moment  of  extreme  tension. 

Of  the  various  internal  remedies  to  stimulate  uterine  action,  ergot 
should,  in  the  first  stage  of  labor,  be  unqualifiedly  proliibited.  In 
spite  of  numerous  favorable  experiences  from  its  use,  its  tendency  to 
intensify  tonic  contraction  of  the  involuntary  muscular  fibers  makes 
it  always  a  perilous  drug.  The  enthusiastic  praises  of  quinine  by  Drs. 
Fordyce  Barker  and  Albert  H.  Smith,  of  Philadelphia,  warrant  fur- 
ther trials  of  its  efficacy.  Dr.  Smith  says :  "  I  do  not  hesitate  to  give 
it  in  every  case,  because,  even  where  there  is  no  decided  inertia  at  the 
onset  of  labor,  there  may  be  failure  of  the  powers  of  the  mother  from 


I 


ANOMALIES  OF  THE  EXPELLENT  FORCES.  459 

early  exhaustion  and  fatigue,  and  we  get  the  benefit  of  the  qiiinia  in 
diminishing  this  tendency  and  also  in  promoting  the  condensation  of 
the  uterine  fiber  after  the  delivery  of  the  placenta,  thus  lessening  the 
dangers  of  post-])artuni  haemorrhage  and  the  annoyances  of  the  after- 
pains  so  commonly  resulting  from  a  slow  condensation  of  the  uterine 
muscle."*  He  recommends  the  bisulphate  in  a  fifteen-grain  dose, 
which  he  declares  acts  altogether  beneficially  as  a  stimulant  to  the 
normal  uterus.  The  other  agents  mentioned  as  possessing  direct  or 
incidental  ecbolic  properties  are  now  chiefly  of  historic  interest. 

Irregular  Pains  in  the  Second  Stage  of  Labor. — In  many  cases  the 
pains  maintain  their  normal  quality  until  the  completion  of  the  first 
stage  of  labor  and  the  descent  of  the  head  to  the  floor  of  the  pelvis. 
AVlien  in  the  second  stage  of  labor  the  pains  become  inefficient  and 
lose  their  expulsive  character,  the  non-advance  of  the  head  is  usually 
attributed  to  a  rigid  perinasum.  But  it  is  a  matter  of  every-day  expe- 
rience that  with  really  good  pains  and  normal  head  mechanism  the 
perineum  speedily  loses  its  rigidity.  Of  course,  it  is  not  denied  that 
in  primiparffi  the  organic  changes  which  effect  the  softening  of  the 
perinteum  need  for  their  accomi^lishment  relatively  stronger  pains  than 
in  multipara.  The  faulty  action  of  the  expellent  forces  in  the  second 
stage  is  due  either  to  exhausted  nerve-power  or  to  excessive  uterine 
retraction.  In  the  former  case,  labor  becomes  powerless  from  the 
feeble  character  of  the  juiius;  in  the  latter,  it  results  from  the  with- 
drawal upward  of  the  uterine  muscle,  and  the  consequent  lessening  of 
the  intra-uterine  pressure.  These  cases  of  retraction  are  worthy  of 
special  consideration.  Thus,  Hofmeierf  found  in  a  number  of  in- 
stances where  the  head  rested  on  the  pelvic  floor  that  the  contraction 
ring,  which  was  made  out  by  palpation  through  the  abdominal  walls, 
was  situated  at  from  five  to  seven  inches  above  the  symphysis  pubis, 
so  that  the  contractile  portion  of  the  uterus  covered  not  more  than 
one  third  of  the  foetus.  Under  such  circumstances,  while  the  ^jatient 
suffers  from  intense  pain,  the  contractions  of  the  partially  emptied 
uterus  do  not  possess  the  force  to  overcome  the  resistance  of  a  rigid 
perinaeum. 

Treatment  — In  all  cases  of  protracted  second  stage,  before  decid- 
ing upon  the  existence  of  uterine  irregularity,  both  the  bladder  and 
the  bowels  should  be  emptied,  and  care  should  be  taken  to  exclude  the 
existence  of  obstruction  from  the  bony  pelvis  If  the  only  resistance 
to  be  overcome  is  that  furnished  by  the  soft  parts,  weak  pains  should 
be  re-enforced  by  the  action  of  the  abdominal  muscles.  After  rotation 
of  the  head  is  completed,  a  new  vis  a  tergo  may  be  supplied  by  press- 
ure applied  to  the  breech  through  tlie  abdominal  walls  after  the  method 

*  Albert  IT.  Smith,  Retarded  Dilatation  of  the  Os  Uteri  in  Labor,  p.  27. 
+  IIoFMErER,  Ueber  Contraetionsverhaltnisse  des  kreissenden  Uterus,  Ztschr.  L 
Greburtsh.  u.  Gynack.,  Bd.  vi,  p.  164. 


460  THE  PATHOLOGY  OF  LABOR. 

of  Kristeller,  or  by  the  modified  form  of  expression  recommended  by 
Bidder.*  According  to  the  latter,  the  physician  should  stand  to  the 
left  of  his  patient,  and  grasp  the  breech  of  the  foetus  with  the  right 
hand ;  he  should  then  raise  the  breech  and  fix  it  in  such  a  position 
that  the  pressure  applied  will  be  best  transmitted  through  the  spinal 
column  to  the  cephalic  end— a  point  to  be  determined  by  the  fingers  of 
the  left  hand,  which  should  likewise  control  the  movements  of  the 
head  during  the  period  of  expulsion.  The  force,  the  frequency,  and 
the  length  of  the  acts  of  expression  should  of  course  be  decided  by  the 
judgment  and  experience  of  the  operator. 

'  Where  the  movements  of  flexion  and  rotation  have  been  imper- 
fectly performed,  little  is  to  be  expected  from  any  of  the  forms  of 
expression.  The  available  remedies  are  then  ergot  and  the  forceps. 
Of  these,  the  advantages  of  safety  and  celerity  are  all  on  the  side  of 
the  forceps.  Many  practitioners,  however,  who  have  observed  that  in 
practice  ergot  often  acts  likewise  with  speed  and  safety,  accord  to  it  a 
large  measure  of  confidence.  But  along  with  these  more  fortunate 
experiences  there  is  a  shady  aspect  to  be  remembered.  When  the 
tardy  labor  is  due  to  tonic  retraction,  the  use  of  ergot  is  calculated  to 
aggravate  the  sources  of  delay.  In  other  cases  tonic  retraction  is  the 
direct  result  of  ergotic  action,  and,  as  a  consequence  of  restricted 
utero-placental  circulation,  the  life  of  the  foetus  is  jeopardized.  When, 
therefore,  the  drug  is  used,  the  heart-sounds  of  the  foetus  should  be 
carefully  watched,  and,  with  the  first  signs  of  failing  force,  the  forceps 
should  be  applied  to  rescue  the  child  from  the  impending  danger  of 
asphyxia. 

Note  on  the  Use  of  Ergot  in  Parturition. — Secale  cornutum,  or  ergot, 
the  active  principle  of  which  is  ergotin,  according  to  Buchheim,t  and  ergotic 
jicid,  according  to  Zweifel,}:  is  universally  acknowledged  to  increase  the  fre- 
quency, length,  and  power  of  the  uterine  contractions  during  parturition,  and 
to  finally  induce  a  tetanic  condition  of  the  uterine  muscular  fibers.  Its  action 
upon  the  unimpregnated  uterus  is  the  same  in  kind,  but  less  marked  in  degree, 
and  of  less  constant  occurrence.  Robert,*  on  the  other  hand,  denies  the  ecbolic 
properties  of  either  of  those  constituents.  He  maintains  that  it  is  cornutin, 
which  excites  the  uterine  contractions,  and  that  the  abortifacient  element  is 
sjihacelin  acid,  to  which  also  the  tetanic  rigidity  produced  by  ergot  is  due. 
The  views  of  high  authorities  in  regard  to  the  manner  in  which  these  effects 
are  produced  present  irreconcilable  differences.  Wernich  ||  attributed  the  ecbolic 
properties  of  ergot  to  irritation  of  the  uterine  nervous  centers,   induced   by 

*  E.  Bidder,  Ziir  Beurtheilung  der  Kristeller'schen  Expressionsmethode  bei 
Kopflagen,  Ztschr.  f.  Geburtsh.  u.  Gynaek.,  Bd.  iii,  p.  241. 

\  BucHHEiM.  Schmidt's  Jahrb.,  vol.  clxiv,  p.  12. 

t  ZwEiFEL,  Ueb.  d.  Secale  corn..  Arch.  f.  exp.  Pathol.,  vol.  iv.  1875.  p.  407. 

*  KoBERT.  Arch,  f.exp.  Patliologie  ii.  Pathol..  Bd.  xviii,  p.  31G. 

I'  Werxich,  Einige  Versuch.  ub.  d.  Miilterk.,  Beitrag.  z.  Geburtsh.,  vol.  iii,  1874, 
p.  102. 


ANOMALIES   OP  THE  EXPELLENT  FORCES.  461 

arterial  anaemia  of  the  spinal  cord  and  of  the  uterine  tissues.  This  anaemia  is 
referred  by  him  to  loss  of  tone  in  and  dilatation  of  the  veins,  whereby  venous 
congestion,  leading  to  secondary  arterial  anaemia,  is  produced.*  Other  ob- 
servers assume  a  primary  contraction  of  the  capillaries,  with  a  consequent  in- 
creased arterial  pressure,  as  the  source  of  the  anaemic  irritation  of  the  nerve- 
centers;  while  still  others  believe  direct  stimulation  of  the  uterine  muscular 
fibers  by  the  ergot  to  be  the  cause  of  their  exaggerated  contractility,  t 

Kohler  refers  the  uterine  contractions  producea  by  ergot  to  increased  irrita- 
bility of  the  peripheral  nerves,  in  conjunction  with  anaemia  of  the  spinal  cord.J 
These  conflicting  views  pertain  chiefly  to  points  of  purely  theoretical  interest, 
and  need  not  prevent  the  obstetrician  from  obtaining  a  clear  conception  of  his 
duty  in  the  practical  administration  of  ergot.  The  above-mentioned  incontro- 
vertible facts  concerning  its  operation  sufiice  to  guide  tlie  physician  in  the  em- 
ployment of  this  useful  drug,  even  if  he  be  unable  at  present  to  definitively 
decide  regarding  the  exact  mechanism  of  its  physiological  action. 

Ergot  should  never  be  exhibited  during  the  first  stage  of  labor,  because  the 
tetanic  uterine  contractions,  which  it  substitutes  for  the  normal  rhythmical  ones, 
tend  to  prevent  the  further  dilatation  of  the  os  uteri  and  to  deprive  the  foetus 
of  its  blood-supply  through  the  constriction  of  the  uterine  vessels.  Should  the 
membranes  have  ruptured  before  the  termination  of  the  first  stage,  the  adminis- 
tration of  ergot  would  endanger  the  life  of  the  foetus  by  causing  undue  pressure 
to  be  exerted  upon  the  umbilical  cord.  We  should  also  abstain  from  the  use  of 
ergot  during  the  second  stage,  unless  it  seem  necessary  as  a  pro^^hylactic  against 
post-partum  haemorrhage.  Even  under  these  circumstances  it  should  never  be 
administered  if  there  be  the  slightest  mechanical  obstacle  to  delivery,  or  if  the 
fetal  head  be  high  up  in  the  pelvic  canal.  Spiegelberg*  insists  upon  the  neces- 
sity of  carefully  observing  the  fetal  heart  after  the  use  of  ergot,  in  order  that 
instrumental  delivery  may,  in  case  of  threatened  asphyxia,  be  promptly  resorted 
to.  Benicke  records  twenty-seven  cases  in  which  ergot  was  administered  during 
the  second  stage  on  account  of  inertia  uteri.  Spontaneous  delivery  occurred  in 
only  seven  of  these  cases.  ||  Ergot  is  not  specially  adapted  to  the  arrest  of  haem- 
orrhage accompanying  abortion.  In  these  cases,  and  in  haemorrhage  caused 
by  retained  shreds  of  the  fetal  envelopes,  the  appropriate  treatment  consists  in 
the  tampon  and  in  subsequent  complete  evacuation  of  the  uterine  cavity.  The 
only  imperative  exhibition  of  ergot  is  presented  by  the  occurrence  of  post- 
partum  haemorrhage  resulting  from  uterine  atony. ^  The  unyielding,  tetanic 
uterine  contractions  which  it  produces  act  most  beneficently  by  occluding  the 
orifices  of  the  bleeding  vessels.  Even  under  these  circumstances  it  should,  how- 
ever, be  withheld  until  after  the  expiilsion  of  the  placenta,  lest  the  uniform 
uterine  contractions  lead  to  its  prolonged  retention  or  interfere  with  manual 
efforts  for  its  extraction. 

Irregular  Pains  in  tJie  Third  Stage  of  Labor. — The  tardy  expul- 
sion of  the  placenta,  due  to  atony  of  the  uterus,  is  of  rare  occurrence 

*  Wermch,  op.  cit.,  p.  97. 

f  Benicke,  Ueb.  Anwend.  d.  Mutterk.  in  d.  Geburtsh.,  Ztschr.  f.  Geburtsh.  u 
Gynaek.,  vol.  lii,  1878,  p.  174. 

X  Kohler,  Schmidt's  Jahrb.,  vol.  clxiv,  p.  14. 

*  Spiegelberg,  Lehrb..  p.  414.  ||  Benicke,  op.  cit.,  p.  178. 
^  ScHROEDER,  Lehrb.,  fifth  edition,  p.  471. 


462  THE  PATHOLOGY  OF  LABOR. 

when  the  Crede  method  of  expression  is  uniformly  practiced.  As,  in 
rehixed  conditions  of  the  uterus,  blood  pours  from  the  patulous  mouths 
of  the  torn  utero-placental  vessels  into  the  fundus,  a  free  external 
discharge  of  blood  follows  of  necessity  whenever  contractions  are  ex- 
cited—a fact  to  be  borne  in  mind  by  an  unpracticed  obstetrician,  lest 
he  mistake  the  simple  conversion  of  an  internal  into  an  external 
hajmorrhage  for  one  produced  by  the  manipulations  which  have  been 
recommended.  The  whole  subject  of  atony  in  the  third  stage  is,  how- 
ever, so  closely  associated  with  the  occurrence  of  post-partum  haemor- 
rhage that  its  specific  consideration  will  be  reserved  for  separate  study 
in  connection  with  the  hemorrhages  which  take  place  during  and 
subsequent  to  labor. 

After  the  birth  of  the  child,  retraction  of  the  uterus  is  Nature's 
safeguard  against  hajmorrhage.  As  a  result  of  the  abuse  of  ergot,  or, 
in  other  cases,  from  an  abnormal  adherence  of  the  jjlacenta,  such  an 
extreme  degree  of  retraction  may  be  reached  before  the  completion  of 
the  third  stage  as  to  lead  to  the  imprisonment  of  the  placenta  within 
the  uterine  cavity.  In  these  cases  complete  retraction  in  the  body  of 
the  uterus  is  prevented  by  the  presence  of  tlie  jDlacental  mass.  Below 
the  latter,  where  no  obstacle  is  opposed  to  the  shortening  of  the  mus- 
cular fibers,  a  constriction  results.  The  stricture  is  most  pronounced 
at  the  contraction  ring.  The  lower  uterine  segment  and  the  cervix 
proper  are  usually  in  a  sub-paralytic  condition,  and  widen  from  above 
downward  to  the  vaginal  insertion.  From  the  shape  thus  imparted 
to  the  uterus  this  condition  is  generally  known  as  an  "hour-glass 
contraction."  When  met  with  for  the  first  time,  it  is  apt  to  prove 
extremely  puzzling.  In  following  the  cord  upward,  its  continuation 
through  the  stricture  is  sometimes  overlooked.  In  several  cases  I 
have  known  the  pulpy  mucous  membrane  of  the  lower  segment  to  be 
mistaken  for  an  adherent  placenta,  and  have  been,  in  consequence, 
summoned  to  assist  in  its  removal. 

Treatment.— By  patient  waiting,  relaxation  of  the  stricture  usually 
takes  place  spontaneously.  The  result  may  be  promoted  by  the  hypo- 
dermic injection  of  morphine,  combined  with  atropine.  It  is  not,  how- 
ever, altogether  safe  to  leave  the  patient  before  the  expulsion  of  the 
placenta  has  taken  place;  for,  exceptionally,  the  muscular  fibers  of 
the  body  of  the  uterus  may  relax  prior  to  those  of  the  lower  segment, 
and  thus  haemorrhage  may  result.  Injections  of  ice-cold  water  were 
recommended  in  such  cases  by  Seyfert,  as  tending  not  only  to  restrain 
hajmorrhage,  but  to  promote  regular  expulsive  uterine  action.  Forci- 
ble dilatation  is  rarely  necessary,  and  should  be  reserved  for  hemor- 
rhages of  an  alarming  character.  In  nearly  all  cases,  however,  it  is 
practicable,  even  in  extreme  examples,  to  extract  the  placenta  in  a 
short  time  without  force  or  violence.  The  plan  I  have  followed  of 
late  years,  with  uniform  success,  consists  in  introducing  the  index  and 


ANOMALIES  OP  THE  EXPELLENT  FORCES.  403 

middle  fingers,  with  the  whole  hand  in  the  vagina,  to  the  point  of 
constriction.  Then,  by  pressing  the  uterus  downward,  the  fingers 
are  brought  in  contact  with  the  pracen"tal  border,  Now,  it  is  only 
necessary  to  draw  a  single  cotyledon  into  the  canal  to  render  the 
further  extraction  a  matter  of  certainty.  Under  the  pressure  of  the 
soft  placental  mass  the  stricture  relaxes  slowly.  By  combining  ex- 
pression with  slight  traction,  the  delivery  is  surely  accomplished.  The 
principal  difficulty  of  the  operation  lies  in  the  manipulations  needful 
to  bring  the  placenta  at  the  outset  to  the  point  of  stricture,  but  this 
difficulty  can  be  pretty  certainly  overcome  by  patience  and  the  deter- 
mination to  succeed.  During  the  period  of  withdrawal  the  operator 
should  be  content  with  a  very  slow  progression,  proportioned  to  the 
yielding  of  the  stricture ;  otherwise,  the  presenting  portion  of  the 
placenta  tears  away,  when  the  labor  expended  is  lost. 

Painful  Labors. — In  nearly  all  forms  of  abnormal  uterine  contrac- 
tions the  pain  of  labor  reaches  a  pathological  degree  of  intensity. 
Especially  we  have  had  occasion  to  call  attention  to  the  intolerable 
suffering  in  cases  of  long-continued  reciprocal  pressure  between  the 
uterus  and  its  contents. 

But  acute  suffering  sometimes  attends  upon  the  preliminary  stages 
of  labor.  During  the  latter  days  of  pregnancy  in  primipara?,  often 
for  a  few  hours  only  preceding  the  advent  of  true  labor-pains  in  mul- 
tipara?, contractions  occur  which  normally  scarcely  attract  the  atten- 
tion of  the  patient.  In  rare  instances,  however,  the  suffering  they  occa- 
sion is  extreme.  In  hysterical  women  these  preliminary  pains  are  often 
of  an  agonizing  character,  rendering  it  necessary  to  resort  for  their 
relief  to  such  palliatives  as  the  warm  bath,  opium,  and  chloroform. 

But,  even  where  hysteria  does  not  exist  as  a  cause,  the  pains  may 
be  so  severe,  while  the  cervix  has  still  its  normal  length,  that  the 
woman  believes  herself  in  labor,  and,  indeed,  the  contractions  are  as 
painful  as  in  actual  labor.  There  are  no  febrile  symptoms  indicative 
of  inflammation  either  of  the  uterus  or  of  its  appendages.  The  pain 
is  like  that  in  muscular  rheumatism.  Though  the  term  rheumatism 
of  the  uterus  is  often  applied  to  this  condition,  its  pathology  is  uncer- 
tain. It  is  very  probable  that  practitioners  confound  together,  under 
the  foregoing  title,  a  number  of  distinct  affections,  such  as  hysterical 
hyperesthesia,  intestinal  irritability,  and  the  early  stages  of  inflamma- 
tion. Excluding  these  morbid  conditions,  there  remains  a  class  of 
cases  practically  important  from  the  disappearance  of  the  pain  upon 
the  induction  of  intense  diaphoresis.  Patients  who  for  days  have 
been  treated  with  hypodermic  injections  of  morphine  with  only  mod- 
erate results  are  often  relieved  as  if  by  magic  by  placing  them  in  a 
warm  bath,  and  then  covering  them  with  blankets,  giving  in  addition 
hot  drinks  and  Dover's  powder,  until  they  become  bathed  in  abundant 
perspiration. 


^Q^  THE  PATHOLOGY  OF  LABOR. 

It  is  often  difficult  toward  the  close  of  preguancy  to  distinguish 
between  colic-pains  due  to  fecal  accumulation  or  the  presence  of  gases 
in  the  stomach  and  intestines,  troubles  to  which  pregnant  women  are 
especially  disposed,  and  uterine  contractions  of  a  painful  character. 
Indeed,  in  the  former  case  the  uterus  becomes  involved  to  some  ex- 
tent, so  that  the  cervix  is  felt  during  a  cramp  to  simultaneously 
harden.  Moreover,  after  labor  has  actually  begun,  it  may  become 
complicated  by  colic-pains,  which  exercise  in  turn  a  suspensive  influ- 
ence upon  parturition.  But  the  colic-pains  are  themselves  inter- 
mittent, and  are  therefore  liable  to  be  mistaken  for  those  of  labor. 
Thus,  it  is  possible  to  become  involved  in  perplexities  which  time 
alone  can  solve.  Even  when  we  have  made  out  the  diagnosis  of 
"  false  labor,"  and  give  an  opiate  for  the  relief  of  the  patient,  it  may 
happen  that  the  first  result  of  quieting  the  pain  may  be  the  accelera- 
tion of  labor.  AVhen  this  does  not  occur,  we  should  guard  against  the 
return  of  the  trouble  by  clearing  out  the  bowels  by  purgatives  or 
enemata. 

In  normal  labors,  the  pulse  becomes  more  rapid  at  the  beginning 
of  each  pain,  and  continues  to  increase  in  frequency  until  the  pain  has 
reached  its  acme,  after  which  a  gradual  declination  follows.  But 
sometimes  labor  is  attended  by  marked  febrile  symptoms.  There  exist 
rapidity  of  the  pulse  between  the  pains  and  a  continuous  elevation  of 
temperature.  Now,  if,  at  the  same  time,  the  uterine  contractions  are 
the  source  of  extraordinary  suffering,  there  is  strong  reason  for  sus- 
pecting that  labor  is  complicated  by  inflammatory  conditions  of  the 
organs  concerned  in  parturition.  Thus,  a  latent  pelvi-peritonitis  may 
be  converted  into  the  acute  form  by  the  several  acts  which  comprise 
normal  labor,  or  the  prolonged  tonic  contraction  of  the  uterus  upon 
the  foetus  after  the  rupture  of  the  membranes,  especially  in  neglected 
shoulder  presentations  and  in  contracted  pelves,  may  give  rise  to  inflam- 
matory affections  in  the  uterus  itself.  Again,  in  other  cases,  a  salpin- 
gitis, especially  if  of  the  purulent  variety,  may  become  the  starting 
point  of  dangerous  local  or  general  peritonitis.  In  either  case  the  co- 
existence of  intense  pain  with  febrile  symptoms  should  awaken  serious 
apprehensions.  Especially  ought  we  to  be  upon  our  guard  against  the 
treacherous  lull  in  the  symptoms  that,  as  a  rule,  takes  place  when 
labor  is  at  an  end.  After  a  day  or  two  we  may  expect  a  chill  and  the 
return  of  the  fever.  In  the  early  stages  of  metritic  and  perimetritic 
trouble,  a  ten-grain  dose  of  calomel  often  exercises  a  beneficent  action 
in  arresting  the  disease.  AVhere  labor  has  so  far  advanced  that  the 
induction  of  artificial  diarrhoea  is  rendered  impracticable,  opiates, 
though  of  inferior  value,  soothe  the  pain,  and  are  our  next  most  valu- 
able resource. 


CONTRACTED   PELVES.  465 

CHAPTER  XXV. 

CONTRACTED  PELVES. 

Varieties. — Frequency. — Diagnosis. — Pelvic  measurements. — Forms  of  the  con- 
tracted pelvis. — Justo-minor  pelves. — Flattened  non-rachitic  pelves. — Rachitic 
ilattened  pelves. — Generally  contracted,  flattened  pelves. — Irregular  forms. — 
Pseudo-osteomalacia. — Scholiosis. — Kyphosis. — Influence  of  contracted  pelves 
during  pregnancy  and  labor. — Influence  upon  the  uterus. — Influence  upon  the 
presentation. — Influence  upon  the  pains. — Influence  upon  the  first  stage  of 
labor. — Influence  upon  the  mechanism  of  labor. — Effects  of  pressure  upon  the 
maternal  tissues. — Influence  upon  the  fetal  head. — Effects  of  pressure  upon 
the  integuments ;  upon  the  cranium. — Prognosis.  ^ 

Ix  contracted  pelves  sometimes  a  single  diameter,  sometimes  ^  ^^ 
the  principal  diameters  are  reduced  below  the  normal  average,  "^iie 
relative  proportion  of  the  parts  may  be  to  a  considerable  extent  pre- 
served, or  the  pelvis  may  have  been  distorted  by  special  morbid  condi- 
tions, giving  rise  to  unequal  development  and  changes  of  outline. 
These  peculiarities  embarrass  all  attempts  at  classification.  Still,  the 
study  of  the  subject  is  greatly  simplified  by  the  fact  that  the  dimin- 
ished space  is,  in  the  great  proportion  of  cases,  located  chiefly  at  the 
brim.  Aside  from  these,  there  remain  a  variety  of  irregular  forms  of 
rare  occurrence,  each  requiring  a  separate  description  and  plan  of 
treatment. 

It  is  to  those  cases  in  which  the  narrowing  is  chiefly  at  the  brim 
that  the  term  "  contracted  pelves "  is  generally  applied.  The  other 
forms  are  all  specially  designated  by  some  qualifying  adjective  defin- 
ing their  character. 

Contracted  pelves  proper  are  divided  into — 

1.  The  pelvis  aequabiliter  justo-minor,  in  which  all  the  diameters, 
from  the  brim  to  the  outlet,  are  diminished  in  very  nearly  equal 
measure. 

2.  The  flattened  pelvis,  contracted  specially  in  the  conjugate  diam- 
eter. In  this  form  the  transverse  diameter  may  be  normal,  or  may  be 
diminished.     Thus,  we  distinguish — 

a.  Simple  flattened  pelves  (transverse  diameter  normal). 

J.  Flattened,  generally  contracted  pelves  (narrowing  in  the  trans- 
verse as  well  as  the  conjugate  diameter).     ^ " 

As  it  is  rare  to  find  two  pelves  possessing  the  same  measure- 
ments, the  question  arises  as  to  the  degree  of  antero-posterior  short- 
ening which  suffices  to  distinguish  the  contracted  from  the  normal 
pelvis. 

It  is  often  customary  to  consider  the  contracted  pelvis  simply  as 
furnishing  a  mechanical  obstacle  to  the  passage  of  the  child's  head ; 
but  this  is  to  overlook  a  great  variety  of  very  important  modifications 
30 


4:^ 


THE  PATHOLOGY  OP  LABOR. 


to  which  it  gives  rise  during  pregnancy  and  labor.  These  remoter 
influences  are  often  observable  in  cases  where  labor,  if  considered  from 
the  standpoint  of  length  alone,  would  be  regarded  as  normal. 

Michaelis*  and  Litzmann,t  whose  investigations  furnish  the  basis 
of  modern  opinion  regarding  the  contracted  pelvis,  place  the  limit  at 
three  and  a  half  inches  for  the  simple  flattened  pelvis,  and  at  four 
inches  for  those  likewise  diminished  in  the  transverse  diameter.  Yet 
even  above  these  limits  the  action  of  the  narrow  pelvis  is  not  rarely 
manifested  in  disturbance  of  the  normal  mechanism  of  labor. 

In  Germany,  Litzmann,  Michaelis,  Spiegelberg,  J  and  Schroeder 
place  the  average  frequency  of  contracted  pelves  at  fourteen  per  cent, 
and  in  my  own  field  of  experience,  in  the  Emergency  and  Maternity 
Hospitals  of  New  York  city,  the  ijimates  of  which  are,  however, 
almost  entirely  of  foreign  birth,  every  variety  and  degree  of  pelvic 
deformity  finds  abundant  illustration.  In  our  native  American  Avomen 
abnormal  pelves  are  rare.  I  frequently  hear  from  country  physicians 
who  attend  lectures  at  the  Belle vue  Hospital  Medical  College  that,  in 
long  years  of  practice,  they  have  never  met  with  a  single  instance. 
Yet  it  is  impossible  to  study  the  cases  of  vesico-vaginal  fistula  re- 
ported by  Dr.  T.  A.  Emmet  *  without  arriving  at  the  conclusion  that 
the  existence  of  contracted  pelves  is  frequently  overlooked.  Certainly 
the  immunity  of  American  women  is  by  no  means  so  absolute  as  to 
Justify  the  neglect  in  which  the  study  of  pelvic  deformity  has  so 
generally  fallen. 

The  Diagnosis  of  Contracted  Pelvis.— The  diagnosis  of  pelvic  de- 
formity is  based  upon  direct  examination.  Certain  facts  in  the  previous 
history  of  the  patient  are  often  of  substantial  value  in  the  way  of  con- 
firmatory evidence,  or  by  directing  attention  to  the  probable  existence 
of  deformity. 

Previous  History. — Inquiry  should  be  instituted  regarding  the  oc- 
currence of  rickets  in  early  childhood,  and  especially  in  this  connection 
as  to  the  period  of  the  appearance  of  the  teeth.  Late  dentition  is  an 
ordinary  sign  of  imperfect  bone  formation.  A  cross  baby,  bottle-fed 
or  improperly  nursed,  suffering  from  repeated  attacks  of  indigestion, 
from  restlessness  at  night,  and  profuse  perspirations,  who  cuts  the  first 
incisor  teeth  in  the  second  year,  has  presumptively  had  rickets.  A 
history  of  this  nature,  even  in  the  absence  of  the  grosser  evidences  of 
rickets,  such  as  the  square  head,  the  pigeon-breast,  the  tumefied  abdo- 
men, small  stature,  spinal  curvature,  enlarged  joints,  and  incurvation 
of  the  long  bones  of  the  extremities,  is  to  be  regarded  with  suspicion. 
Data  of  the  kind  mentioned  are,  however,  often  difficult  to  obtain,  and 

*  Michaelis,  Das  enge  Becken,  Leipsic,  1865. 

t  Litzmann,  Die  Formen  des  Beckens,  Berlin,  1861. 
t  Spiegelberg,  Lehrbuch,  1878,  Bd.  ii,  p.  426. 

*  Emmet,  Vesico- Vaginal  Fistula,  William  Wood,  1868. 


CONTRACTED   PELVES. 


46Y 


it  should  be  borne  in  mind  tiiat  not  every  case  of  mild  rachitis  is  fol- 
lowed by  pelvic  narrowing. 

In'struction  may  likewise  be  obtained  from  the  history  of  previous 
labors.  Though  a  protracted  and  difficult  labor  is  by  no  means  un- 
common in  well-formed  primipar^e,  it  should  stimulate  us,  both  during 
parturition  and  subsequent  to  delivery,  to  make  a  careful  investigation 
as  to  the  capacity  of  the  pelvis.  A  pendulous  abdomen  and  faulty 
presentations  and  positions  of  the  fojtus  occur  with  much  greater  fre- 
quency in  contracted  than  in  normal  pelves. 

Certain  of  the  rarer  deformities  proceed  from  inflammations  be- 
tween the  sacro-iliac  bones  and  at  the  hip-joint,  from  inequalities  in 
the  length  of  the  limbs,  and  from  spinal  distortion  when  these  diffi- 
culties occur  in  early  childhood. 

Pelvic  Measurements. — The  examination  should  be  made  with  the 
patient  upon  her  back,  placed  preferably  upon  a  hard  table  covered  by 
a  folded  blanket,  or  a  woolen  comforter.  The  head  and  shoulders 
should  be  moderately  elevated,  the  knees  should  be  flexed,  and  the 
pelvis  brought  as  near  to  the  edge  of  the  table  as  possible. 

Facility,  in  the  recognition  of  abnormal  conditions  can  only  be  ac- 
quired by  making  it  a  habit  to  note  the  general  features  of  the  pelvis 
in  every  case  of  labor  which  is  committed  to  our  charge.  By  experi- 
ence we  acquire  a  tolerably  distinct  idea  of  the  relative  thickness  of 
the  bones,  the  inclination  of  the  ilia  to  the  horizon,  the  height  of  and 
the  angle  formed  by  the  symphysis  pubis,  the  size  and  character  of  the 
pubic  arch,  the  length,  breadth,  and 
curvature  of  the  sacrum,  the  position 
of  the  promontory,  and  the  distance 
between  the  ischia. 

More  exact  information  is  deriv- 
able from  direct  measurements  be- 
tween different  prominent  points  in 
the  pelvis.  Various  pelvimeters  have 
been  devised  to  facilitate  the  required 
measurements.  Those  for  determin- 
ing the  distance  between  certain  ex- 
ternal points  are  alone  of  practical 
value.  For  this  purpose  the  circle  of 
Baudelocque  is  the  one  I  have  most 
constantly  employed.  It  requires  to 
be  used  with  caution  on  account 
of  the  spring  of  the  metallic  arms. 
Schultze's  instrument  possesses  the 
advantages  of  greater  firmness  and  portability.  The  points  selected 
for  measurement  should  be  bony  prominences,  easy  of  recognition, 
and  not  covered  by  soft  parts.     They  should  be  such  as  to  allow  us 


Fig.  200. — Baudelocque's  pelvimeter. 


468 


THE  PATHOLOGY  OF  LABOR. 


to  form  at  least  approximative  conclusions  relative  to  the  diameters 
of  the  small  pelvis.  Experience  shows  iis  that,  judged  by  these  rules, 
three  measurements  only  are  possessed  of  real  importance,  viz.,  the 
distances  between  the  anterior  superior  spinous  processes,  the  distances 
between  the  crests  of  the  ilia,  and  the  external  conjugate  diameter. 


Fig.  201.— Schultze's  pelvimeter. 

In  measuring  the  distances  between  the  anterior  superior  spinous 
processes,  the  accoucheur  should  stand  by  the  side  of  his  patient,  and, 
holding  the  arms  of  the  pelvimeter  between  the  thumb  and  fingers, 
apply  the  points  of  the  instrument  to  the  spines  external  to  the  inser- 
tion of  the  sartorious  muscles.  The  points  should  then  be  pushed 
backward  a  number  of  times  along  the  outer  edge  of  the  crests  of  the 
ilia,  until,  after  a  few  trials,  the  greatest  distance  between  the  crests 
has  been  determined.  The  average  distances  thus  obtained  are  nearly 
ten  and  a  quarter  inches  between  the  spinous  processes,  and  eleven 
and  a  half  inches  between  the  crests  of  the  ilia.  A  pelvis  in  which 
these  measurements  are  equal,  or  in  which  the  relations  are  inverted 
(i.  e.,  where  the  distance  between  the  spinous  processes  is  greater  than 
that  between  the  crests  of  the  ilia),  is  rachitic  in  character.  In  rachitic 
pelves  of  the  second  variety  mentioned  it  is  customary  to  select,  in 
measuring  the  distance  between  the  crests,  points  situated  two  and  a 
half  inches  posterior  to  the  spinous  processes. 

Any  considerable  falling  below  the  normal  average  in  these  two 
diameters  would  warrant  the  diagnosis  of  transverse  shortening  in 
the  inner  dimensions  of  the  small  pelvis.  Deductions  as  to  the  degree 
of  shortening  should,  however,  be  made  with  caution,  as  the  relations 
between  the  diameters  of  the  large  and  small  pelves  depend  upon  such 
variable  factors  as  the  thickness  of  the  bones  and  integuments  and 
the  height  and  inclination  of  the  ilia  to  the  horizon. 


CONTRACTED  PELVES.  469 

In  measuring  the  external  conjugate  diameter  the  patient  is  turned 
upon  her  side ;  one  extremity  of  the  pelvimeter  is  then  placed  upon 
the  fossa  just  beneath  the  spinous  process  of  the  last  lumbar  vertebra, 
while  the  anterior  point  is  made  to  rest  upon  the  middle  of  the  upper 
border  of  the  symphysis  pubis.  The  lengtli  of  the  external  conjugate, 
or,  as  it  is  sometimes  termed  from  its  author,  the  diameter  of  Baude- 
locque,  is  normally  about  eight  inches.  Baudelocque  thought  that  by 
deducting  three  inches  from  the  external  conjugate  in  spare  women, 
and  three  and  a  quarter  inches  in  women  of  a  fleshy  habit,  the  conju- 
gata  vera  could  be  determined.  Litzmann  has,  however,  strikingly 
shown  the  fallacy  of  Baudelocque's  deduction.  In  thirty  cases,  where 
he  had  an  opportunity  to  compare  the  measurements  of  the  external 
conjugate  with  the  length  of  the  internal  conjugate  as  determined  sub- 
sequently by  post-mortem  examination,  he  found  the  mean  amount  to 
be  deducted  was  about  three  and  a  half  inches.  However,  the  amount 
in  individual  cases  widely  varied,  owing  to  differences  in  the  thickness 
of  the  bones  and  integuments,  tlie  maximum  amounting  to  nearly 
five  inches,  while  the  minimum  did  not  exceed  two  and  three  fourths 
inches.  But,  while  the  external  conjugate  does  not  enable  us  to  esti- 
mate to  a  fraction  the  length  of  the  antero-posterior  diameter  of  the 
pelvic  brim,  it  furnishes  useful  information  as  to  the  existence  in  gen- 
eral of  flattening.  Thus,  if  the  diameter  of  Baudelocque  measures 
less  than  six  and  one  fourth  inches,  it  may  be  assumed  that  the  pelvis 
is  flattened.  If  the  pelvis  measures  less  than  seven  and  a  half  inches, 
flattening  may  be  assumed  in  half  the  cases.  Above  seven  and  a  half 
inches,  antero-posterior  shortening  is  very  exceptional.* 

For  internal  measurements,  the  only  practical  pelvimeter  is  the 
hand  of  the  accoucheur.  To  be  sure,  it  can  only  determine  with  ex- 
actitude the  diagonal  conjugate,  i.  e.,  the  distance  from  the  lower  bor- 
der of  the  symphysis  pubis  to  the  promontory ;  but  from  the  diagonal 
conjugate  it  is  possible  to  calculate  the  conjugata  vera  with  a  closer 
degree  of  accuracy  than  is  obtainable  by  means  of  any  of  the  ingenious 
instruments  designed  to  measure  directly  the  diameters  of  the  brim. 

To  ascertain  the  diagonal  conjugate,  the  index  and  middle  fingers 
of  the  left  hand  should  be  introduced,  well  oiled,  into  the  vagina.  By 
pushing  the  posterior  vaginal  wall  backward,  the  points  of  the  fingers 
are  made  to  reach  the  sacral  vertebrae.  Then,  following  the  sacrum 
upward,  the  promontory  is  reached.  To  do  this  it  is  necessary  to  sink 
the  elbow,  and  give  to  the  fingers  a  nearly  vertical  direction.  The 
resistance  of  a  rigid  peringeum  and  the  vaginal  wall  is  best  overcome 
by  continued,  steady,  upward  pressure.  It  is  often  possible  by  this 
method  to  reach  the  promontory  in  even  normal  pelves.  During  the 
examination  the  patient  should  be  requested  to  raise  up  her  hips.     The 

*  Litzmann,  Ueber  die  Erkenntniss  des  engen   Beckens,  Volkmann's  SammL 
klin.  Vortr.,  No,  20,  p.  148. 


470 


THE  PATHOLOGY  OF  LABOR. 


promontory  is  recognized  partly  by  its  convex  surface,  and  partly  by 
the  width  of  the  cartilage  which  intervenes  between  it  and  the  ad- 
joining lumbar  vertebra.  In  practice  there  are  two  possible  sources  of 
error,  viz. :  an  angle  may  form  between  the  first  and  second  sacral 
vertebrae  where  the  union  has  been  incomplete,  producing  a  "false 
promontory  "  beneath  the  true  one ;  or  the  upper  surface  of  the  first 
lumbar  vertebra  may  project  in  such  a  way  as  to  be  mistaken  for  the 
promontory  in  cases  where  the  latter,  as  sometimes  happens,  forms 
with  the  spinal  column  a  very  obtuse  angle.*  Such  deviations  are  not 
without  practical  interest,  as  the  prognosis  is  rendered  less  promising 
when  the  head,  in  place  of  a  single  .point  of  contact,  has  to  overcome 
the  resistance  offered  by  the  surface  of  an  entire  vertebra. 

The  measure  of  the  diagonal  conjugate  is  taken  by  pressing  the 
middle  finger  firmly  against  the  most  salient  portion  of  the  promon- 


'b^ 


Fia.  202.— Normal  inclination      Fig.  20.3.— Diminution  of  angle      Fig.  204.— Increase  of  angle 
of  the  symphysis   pubis.  between  symphysis  and  pel-  between  symphysis  and 

(Spiegelberg.)  vie  brim.  pelvic  brim. 

tory,  while  the  radial  edge  of  the  hand  or  index-finger  is  raised  to  the 
Ugamentum  arcuatum.  The  point  of  contact  with  the  latter  is  then 
carefully  marked  with  the  nail  of  the  index-finger  of  the  right  hand. 
It  is  desirable  in  withdrawing  the  fingers  that  they  maintain,  as  nearly 
as  may  be,  the  position  assumed  at  the  time  of  measurement.  Finally, 
with  a  small  rule,  the  length  from  the  mark  of  the  nail  to  the  tip  of 
the  finger  is  readily  ascertained. 

In  calculating  the  length  of  the  conjugata  vera  from  the  measure 
thus  gained,  it  is  necessary  to  reconstruct  the  triangle  formed  by  the 
two  conjugates  and  the  symphysis  pubis.  The  diagonal  conjugate  is 
the  longest  of  the  three  sides.  The  length  of  the  conjugata  vera  de- 
pends on  the  height  and  inclination  of  the  symjihysis  pubis  and  thj 

*  LiTZMANN,  Ueber  die  Erkenntniss  des  engen  Beckens,  Volkmann's  Samml, 
klin.  Vortr.,  No.  20,  pp.  152,  153. 


CONTRACTED  PELVES.  471 

degree  of  elevation  of  the  promontory  above  the  symphysis,  as  may  be 
readily  seen  by  reference  to  the  diagrams. 

The  height  of  the  symphysis  pubis  may  be  determined  by  the  finger 
through  the  anterior  vaginal  wall.  When  the  symphysis  does  not 
measure  above  one  inch  and  a  half,  the  subtraction  of  two  thirds  of  an 
inch  from  the  diagonal  diameter  will,  under  ordinary  circumstances, 
furnish  very  nearly  the  conjugate.  When  the  symjihysis  exceeds  one 
inch  and  a  half,  three  fourths  of  an  inch  should  be  deducted.* 

The  inclination  of  the  symphysis  pubis  to  the  plane  of  the  brim 
and  the  height  of  the  promontory  above  the  upper  border  of  the  pubes 
can  only  be  estimated.  When  any  unusual  deviations  in  either  of 
these  regards  are  found  to  exist,  some  special  allowance  would  need  to 
be  made  by  way  of  compensation.  It  is  just  here  that  judgment  and 
experience  furnish  the  best  safeguards  against  vital  inaccuracies. 

In  thin  persons  during  the  non-pregnant  state  the  promontory 
can  sometimes  be  easily  reached  through  the  abdominal  walls,  and  an 
estimate  made  of  the  conjugate  by  deducting,  from  the  distance  thus 
obtained  between  the  jDromontory  and  the  symphysis,  the  supposed 
thickness  of  the  intervening  tissues. 

The  transverse  diameters  of  the  pelvic  brim  and  cavity  can  be 
neither  directly  measured  nor  calculated  with  any  degree  of  certainty 
from  other  measurements. 

There  are  certain  other  dimensions  which  we  find  useful  to  deter- 
mine in  the  rarer  forms  of  distortion,  and  which  will  be  mentioned  in 
their  proper  connections.  For  the  three  forms  of  contracted  pelvis 
which  at  present  engage  our  attention,  four  measurements  alone  are 
of  practical  value — viz.,  the  distance  between  the  anterior  superior  spi- 
nous processes ;  the  distance  between  the  crests  of  the  ilia ;  the  exter- 
nal conjugate ;  and  the  conjugata  diagonalis. 

The  Three  Principal  Forms  of  Contracted  Pelvis. 

The  Pelvis  JEquabiliter  Justo-minor,  or  Symmetrically  Contracted 
Pelvis. — This,  the  rarest  of  the  three  forms,  presents  to  the  casual 
view  the  appearance  of  a  normal  pelvis,  except  that  the  diameters  from 
the  brim  to  the  outlet  are  reduced  in  nearly  equal  measure.-  We  dis- 
tinguish two  varieties  of  this  pelvis :  1.  In  the  commoner  variety  the 
woman  may  be  of  small,  medium,  or  large  stature,  and  her  figure  thick- 
set, or,  on  the  contrary,  graceful  and  slender.  Nothing  in  either  her 
size  or  carriage  is  indicative  of  any  abnormal  condition.  The  pelvic 
bones  themselves,  both  in  their  structure  and  in  their  connections  with 
one  another,  are  free  from  all  traces  of  morbid  action.  They  are  sim- 
ply below  the  standard  size.  The  pelvis  as  a  whole  is  of  the  feminine 
type.     Litzmann  has  shown,  however,  that  in  the  justo-minor  pelvis 

*  Spiegelberg,  o/j.  cif.,  p.  433. 


472 


THE  PATHOLOGY  OP  LABOR. 


the  relations  of  the  different  parts  to  one  another  are  not,  as  a  rule, 
absolutely  the  same  as  in  the  normal  pelvis.  Thus,  there  is  diminished 
width  of  the  sacrum,  due  in  special  degree  to  the  small  size  of  the  alae ; 
the  rotation  forward  of  the  promontory  and  the  curving  of  the  lower 
extremity  of  the  sacrum  are  less  pronounced;  the  concavity  of  the 
sacrum  in  the  transverse  direction  is  increased;  the  posterior  sacral 
surface  is  nearly  on  a  level  with  the  posterior  superior  spinous  processes 
in  place  of  sinking  forward  between  the  ilia ;  the  height  of  the  anterior 
and  lateral  walls  is  proportionately  lessened  ;  and,  finally,  there  is  often 
an  increase  in  the  angle  which  the  symphysis  pubis  forms  with  the 
conjugate.* 

These  peculiarities  point  to  a  premature  arrest  in  the  development 
of  the  bones,  whereby  the  pelvis  retains  something  of  the  infantile 
type.  The  causes  of  arrest  are  in  most  cases  traceable  to  general  dis- 
turbances of  nutrition  during  early  childhood,  such  as  scrofula  and 
chlorosis,  to  rickets,  which  in  place  of  leading  to  deformity  exception- 
ally exerts  its  influence  in  the  suspension  of  bone-growth,  and  in  rare 
cases  to  the  influence  of  hard  labor  and  the  carrying  heavy  weights 
before  the  completed  development  of  the  body.  A  few  cases  in  which 
no  morbid  conditions  can  be  elicited  from  the  history  of  tlie  patient 
may  perhaps  be  referred  to  some  original  defect  in  the  primitive  ma- 
terial from  which  the  bones  were  built  up.  Cases  have  been  reported 
in  which  this  anomaly  appeared  to  be  hereditary,  f 

2.  In  veritable  dwarfs  the  diminutive  size  of  the  pelvis  may  simply 
correspond  to  the  Lilliputian  proportions  of  the  entire  skeleton.  These 
so-called  dwarf  pelves — pelves  nance — are  of  the  regular  feminine  type, 
but  the  bones  are  slight,  and  united,  as  in  the  child,  by  cartilage. 
They  are  extremely  rare.  In  pelves  of  this  variety  the  highest  degree 
of  contraction  is  observed.  J 

Diagnosis. — In  i\ve  justo-minor  pelvis  all  the  external  diameters  are 
diminished.  At  the  same  time  rickets  is  excluded  by  the  normal  re- 
lations existing  between  the  spines  and  the  crests  of  the  ilia  {vide  p. 
475).  The  diagonal  conjugate  is  lessened.  In  estimating  the  conju- 
gata  vera  it  is  necessary  carefully  to  notice  the  height  of  the  promon- 
tory and  the  inclination  of  the  anterior  pelvic  wall,  as  these  are  some- 
times exaggerated  and  call  for  an  increase  in  the  amount  to  be  de- 
ducted.*    By  careful  palpation  of  the  two  sides  of  the  pelvis  with  the 

*  LiTZMANN,  Die  Formen  des  Beekens,  Berlin,  p.  40. 

f  MicHAELis,  Das  enge  Becken,  herausgegeben  von  Litzmann,  p.  190  ;  vide  like- 
wise, L5HLEIN,  Zur  Lehre  voni  Durchweg  zu  engen  Becken,  Ztschr.  f.  Geburtsh.  u. 
Frauenkr.,  Bd.  i,  p.  53. 

X  There  is  a  third  form  of  justo-minor  pelvis,  which  is  the  concomitant  of  un- 
developed organs  of  generation.  As  it  occurs  only  in  sterile  women,  it  possesses 
no  obstetrical  interest. 

*  On  the  contrary,  owing  to  the  shortness  of  the  symphysis  pubis,  as  a  rule,  the 
average  amount  to  be  deducted  is  rather  less  than  in  normal  pelves.    Lohlcin  Kunst- 


CONTRACTED  PELVES. 


473 


half -hand  introduced  into  the  vagina,  the  fact  but  not  the  degree  of 
transverse  shortening  may  be  recognized.  Still,  in  this  way  the  ex- 
istence of  extreme  contraction  would  be  noticed.*     Jjohlein  maintains 


Fig.  205.— Specimens  from  the  Wood  Museum  (Bellevue  Hospital).    Drawn  on  same  scale. 
No.  1.  Normal  pelvis.    No.  2.  Justo-minor  pelvls.t 

that  the  addition  of  four  fifths  of  an  inch  to  the  distance  from  the 
lower  border  of  the  ligamentum  arcuatum  and  the  upper  border  of  the 
great  sciatic  notch,  which  can  be  measured  by  the  finger  without  great 

hiilfe  bei  der  allg.  Beckenenge)  found  the  average  in  eighteen  cases  was  three  fifths 
of  an  inch. 

*  LoHLEiN,  Zur  Becken-Messung,  Ztschr.  f.  Geburtsh.  und  Gynaek.,  vol.  xi,  part 
i,  p.  33. 

f  Primipara,  aged  twenty-three.  In  labor  three  days  previous  to  my  seeing  her. 
Waters  all  escaped.  Large  scalp-tumor  reaching  nearly  to  vulva.  Cervix  rigid. 
Os  one  third  dilated  and  pushed  down  by  scalp-tumor.  Forceps  tried.  Afterward 
perforation  and  craniotomy.  Chin  tilted  and  head  brought  through  the  pelvis  by 
the  fronto-mental  diameter.  Patient  died  on  third  day.  Extensive  marks  of  press- 
ure in  the  bladder  opposite  pelvic  rami.  Small  circular  perforation  of  uterus  oppo- 
site promontory.  Conjugate  diameter  three  inches.  Transverse  diameter  of  brim 
four  and  a  half  inches.  Slight  Naegele  obliquity  on  left  side.  Patient  was  fifty- 
nine  inches  in  height,  and  presented  no  signs  of  rickets. 


^/j^  THE  PATHOLOGY  OF  LABOR. 

difficulty,  furnishes  a  close  approximation  to  the  length  of  the  trans- 
verse diameter.  In  ordinary  cases,  it  is  fortunately  safe  to  base  prac- 
tice upon  the  length  of  the  antero-posterior  diameter. 

Flattened  Pelvis. — AVe  have  seen  that  the  characteristic  of  this 

form  is  a  shortened  conjugate  diameter.     The  transverse  diameter  re- 

^    mains  at  the  same  time  normal,  or  may  sink  below  the  standard.     A 

special  distinction  is  likewise  to  be  made  between  the  flattened  pelves 

of  non-rachitic  and  rachitic  origin  : 

1.  The  flattened  non-rachitic  form  is  the  most  frequent  variety  of 
contracted  pelvis.  At  a  first  glance,  or  previous  to  measurement,  it 
often  produces  the  impression  of  a  normal,  well-formed  pelvis.  It  is 
occasioned  by  a  sinking  of  the  sacrum  downward  and  inward  between 
the  two  ilia.  As  this  movement  takes  place  without  any  forward  rota- 
tion of  the  promontory,  the  antero-posterior  shortening  is  not  confined 
to  the  brim,  but  extends  throughout  the  entire  pelvic  cavity.  Extreme 
contraction  is  uncommon,  the  length  of  the  conjugate  rarely  falling 
below  three  inches.  The  flattening  is  of  necessity  associated  with  a 
compensating  increase  in  the  transverse  diameter.  As,  however,  the 
flattened  non-rachitic  pelvis  is  usually  from  the  outset  of  small  sizet, 
the  compensation  hardly  suffices  to  give  to  the  transverse  diameter 
more  than  the  normal  dimensions.  Indeed,  it  is  not  infrequent  to 
find  a  slight  lessening  in  the  transverse  diameter  associated  with  aur 
tero-posterior  contraction. 

There  is  nothing  definitely  settled  regarding  the  etiology  of  this 
deformity.  It  has  been  attributed  to  lifting  and  carrying  heavy  bur- 
dens before  the  age  of  puberty,  to  incompletely  developed  rickets,  and 
to  retarded  development. 

During  life  it  is  not  easy  to  distinguish  between  this  form  and  that 
of  the  symmetrically  contracted  pelvis.  In  both  the  external  signs  of 
rickets  are  absent,  the  relations  between  the  spines  and  crests  of  thoi 
ilia  normal,  and  in  both  all  the  external  diameters  may  be  somewhat 
diminished.  The  stature  of  the  individual  furnishes  no  clew;  for, 
though  both  forms  occur  rather  more  frequently  in  diminutive  persons, 
there  are  numerous  exceptions  to  the  rule.  The  sinking  of  the  sacrum 
between  the  ilia  is  not  easy  to  recognize.  In  a  well-marked  example, 
however,  the  relatively  greater  shortening  of  the  conjugata  externa  and 
the  diagonal  conjugate,*  with  the  difficulty  of  palpating  the  inner  sur- 
face of  the  pelvic  lateral  walls,  furnish  the  prominent  points  for  guid- 
ance. Sometimes,  when  no  bony  union  has  formed  between  the  first 
and  second  sacral  vertebrae,  a  double  promontory  may  be  left. 

*  In  reckoning  the  true  conjugate  from  the  diagonal  diameter,  the  same  reduc- 
tion needs  to  be  made  as  in  the  normal  pelvis,  for,  though  the  outward  slant  of  the 
symphysis  is  increased,  this  is  compensated  for  by  the  diminished  height  of  the 
symphysis  and  low  position  of  the  promontory.  (Litzmann,  Volkmann's  SammL 
klin.  Vortr.,  No.  20,  p.  160.) 


I 


CONTRACTED  PELVES. 


475 


2.  The  rachitic  form  of  flattened  pelvis  presents  the  following  char- 
acteristics : 

The  bones  are  of  small  size,  but  usually  of  normal  texture.  Some- 
times, however,  they  are  thin,  and  even  translucent,  while  in  other 
instances  they  may  be  unusually  compact  and  thickened.  The  ilia  are 
flattened,  and  run  in  a  nearly  horizontal  direction.  The  anterior  su- 
perior spinous  processes  flare  outward,  so  that  the  distance  between 
them  dift'ers  little  from  that  between  the  widest  points  of  the  crests. 
The  promontory  projects  inward  toward  the  symjjhysis  pubis.  The 
upper  portion  of  the  sacrum  sinks  inward  between  the  ilia,  and  lies 
farther  in  front  of  the  posterior  superior  spinous  processes  than  in  the 
normal  pelvis.  The  upper  portion,  too,  is  directed  nearly  horizontally 
backward,  while  the  extremity,  usually  at  the  fourth  or  fifth  sacral  ver- 
tebra, is  bent  sharply  for- 
ward. The  anterior  sacral 
surface  loses  its  transverse 
concavity,  and  becomes 
either  fiat  from  side  to 
side,  or  convex  from  the 
bulging  forward  of  the  sa- 
cral vertebra.  The  antero- 
posterior shortening  of  the 
brim  is  accompanied  by  a 
compensating  increase  in 
the  transverse  diameter. 
As,  however,  the  rachitic 
pelvis  is  originally  under- 
sized, the  transverse  diameter  rarely  exceeds  normal  dimensions.  The 
horizontal  rami  of  the  pubes  are  flattened,  and  the  acetabula  are  di- 
rected to  the  front.  The  cartilage  of  the  symphysis  pubis  generally 
projects  inward,  the  pectineal  line  is  often  unusually  sharp,  and  at 
times  terminates  at  the  insertion  of  the  psoas  muscle  in  a  projecting 
spine.  Below,  the  ischia  diverge  from  one  another,  and  the  arch  of 
the  pubes  is  widened. 

The  result  of  these  changes  is  to  produce  a  shallow  pelvis,  with 
contraction  at  the  brim  and  widening  at  the  outlet.  The  shape  of 
the  brim  varies  between  a  long  ellipse  and  that  of  a  heart  or  kidney, 
the  different  degrees  of  variation  depending  upon  the  extent  of  the 
displacement  forward  of  the  promontory.  Externally,  owing  to  the 
horizontal  position  of  the  sacrum,  a  depression  exists  in  the  lumbar  re- 
gion, the  sulcus  between  the  nates  is  broad  and  superficial,  and  the 
anal  orifice  is  exposed  to  view. 

To  apf)reciate  the  rachitic  pelvis,  it  is  necessary  to  bear  in  mind  the 
changes  wrought  by  rickets  in  the  bony  structures.  In  the  physiolog- 
ical growth  of  the  pelvic  bones,  new  cell-elements  develop  beneath  the 


Fig.  306.— Flattened  rachitic  pelvis.    (Wood's  Museum.) 


^^Q  THE  PATHOLOGY  OF  LABOR. 

periosteum  and  adjacent  to  the  cartilaginous  borders  upon  the  articular 
surfaces.  These  cell-elements  promptly  ossify,  and  thus  provision  is 
made  for  the  increase  of  the  bones  in  extent  and  thickness.  Simulta- 
neously with  the  formation  of  the  new  bone,  medullary  spaces  are  pro- 
duced in  the  bony  tissues  by  a  process  of  absorption.  Now,  in  rickets, 
while  the  new  cell-elements  are  deposited  in  such  numbers  that  the 
preparatory  layer  is  often  five  to  ten  times  the  normal  thickness,  the 
process  of  ossification  is  suspended  or  im])erfectly  performed.  Thus, 
the  rachitic  pelvis  consists  of  a  number  of  more  or  less  firm,  bony 
masses,  covered  with  soft  osteoid  layers,  with  broad  cartilaginous  bor- 
ders at  the  articular  surfaces.  These  changes  combine  to  increase  the 
pliability  of  the  pelvis,  and  to  retard  its  growth. 

The  pelvic  deformity  resulting  from  rickets  is  mainly  due  to  the 
weight  of  the  superimposed  body.  The  pressure  from  above  which  the 
trunk  exerts  pushes  the  promontory  forward  toward  the  median  line. 
At  the  same  time  the  upper  portion  of  the  sacrum  rotates  upon  its 
transverse  axis,  so  that  its  posterior  aspect  is  nearly  on  a  line  with  the 
horizon.  The  bodies  of  the  vertebrae  sink  downward  between  the  flex- 
ile wings,  whereby  the  concavity  of  the  sacrum  from  side  to  side  is 
effaced.  The  pliant  border  of  the  iliac  articulation  yields  somewhat, 
and,  as  it  is  drawn  inward  by  the  sinking  of  the  sacrum,  the  traction 
of  the  strong  sacro-iliac  ligaments  ajoproximates  the  posterior  superior 
spinous  processes  to  one  another.  The  traction  of  the  sacro-tuberous 
and  sacro-spinous  ligaments  aids  in  hooking  forward  the  lower  extrem- 
ity of  the  sacrum,  though  to  this  deformity  the  pressure  exercised 
upon  the  end  of  the  spinal  column  by  the  half-sitting,  half -recumbent 
posture  affected  by  rachitic  children  unquestionably  contributes  its  part. 

If  we  regard  the  sacrum  as  a  fulcrum,  and  each  os  innominatum  as 
a  lever,  it  is  evident  that  the  traction  of  the  sacro-iliac  ligaments,  under 
the  pressure  upon  the  sacrum  from  the  trunk,  would  produce  a  separa- 
tion of  the  innominate  bones  in  front  were  it  not  for  their  firm  union 
at  the  symphysis  pubis.  The  result  of  these  two  counteracting  forces 
is  an  increased  incurvation  of  the  bones  at  the  point  of  weakest  resist- 
ance, which  is  situated  near  the  articular  surfaces.  In  advanced  rick- 
ets, where  the  bones  are  plastic  and  willowy,  the  linea  arcuata  is  often 
bent  at  an  angle,  so  that  the  greatest  transverse  diameter  divides  the 
pelvic  brim  into  a  posterior  and  anterior  half.  To  the  latter  belong 
the  acetabula,  to  the  former  the  two  ilia. 

The  outward  direction  of  the  anterior  superior  spinous  processes  is 
probably  due  in  a  measure  to  an  arrest  of  development,  as  the  S-shaped 
curve  of  the  crests  of  the  ilia  does  not  normally  develop  until  after  the 
age  at  which  rickets  usually  makes  its  appearance  (Kehrer).  The  flat- 
tening of  the  ilia  is  partly  due  to  the  drag  of  the  sacro-iliac  ligaments, 
and  partly  to  the  action  of  the  sartorii  and  gluteal  muscles.  The  di- 
vergence of  the  ischia  and  the  wide  arch  of  the  pubes  are  the  product 


CONTRACTED  PELVES.  477 

of  the   increased  transverse  diameter,  and  the  attachments  of  the  ro- 
tator and  adductor  muscles  of  the  thigh.* 

The  diagnosis  of  the  rachitic  form  of  flattened  pelvis  is  easy,  if  the 
characteristic  changes  are  kept  in  mind.  The  prominent  features  to 
which  the  attention  needs  to  be  directed  are ;  the  relations  of  the  dis- 
tances between  the  crista  ilii  and  the  anterior  superior  spinous  pro- 
cesses (diminished  difference,  or  distance,  between  the  anterior  superior 
spinous  processes  may  equal,  or  even  exceed,  that  between  the  crests) ; 
diminished  distance  between  the  posterior  superior  spinous  processes ; 
diminution  of  the  external  conjugate ;  the  form  and  direction  of  the 
sacrum ;  the  shape  of  the  arcus  pubis ;  and  the  marked  projection  of 
the  promontory.  A  false  promontory  at  the  second  sacral  vertebra  is 
not  uncommon.  The  deduction  to  be  made  from  the  conjugata  diago- 
nalis  in  estimating  the  conjugata  vera  averages  the  same  as  in  the  nor- 
mal pelvis.  However,  it  is  in  rachitic  pelves  that  the  widest  variations 
in  this  respect  occur,  making  it  specially  necessary  in  each  case  to  ob- 
serve the  height  of  the  promontory  and  the  length  and  direction  of  the  * 
symphysis  pubis. 

Flattened  Generally  Contracted  Pelves. — In  this  variety  we  distin-         1^ 
guish  likewise  a  rachitic  and  non-rachitic  form,  the  latter  occurring 
rarely,  the  former  with  comparative  frequency. 

The  non-rachitic  form  is  apj^arently  the  joint  product  of  a  small 
justo-minor  pelvis  and  the  forces  which  lead  to  a  sinking  of  the  sacrum 
between  the  ilia.  In  these  pelves  a  short  symphysis  and  a  low  prom- 
ontory contribute  often  to  reduce  greatly  the  difference  between  the 
diagonal  and  the  true  conjugate.  During  life  it  is  difficult  to  distin- 
guish it  from  the  justo-minor  pelvis. 

The  rachitic  form  is  found  usually  in  persons  of  small  stature.  It 
presents  in  a  striking  degree  the  marked  peculiarities  of  the  rachitic 
pelvis.  The  existence  of  transverse  narrowing  is  recognized  by  the 
narrowness  of  the  hips,  by  the  ease  with  which,  in  internal  examina- 
tion, the  side  walls  can  be  felt  with  the  palmar  surface  of  the  half- 
hand,  and  by  the  modifications  it  produces  in  the  mechanism  of 
labor. 

*  While  Litzraann  (Die  Pormen  des  Beckens)  and  Schroeder  (Lehrbuch  der  Ge- 
burtshulfe)  lay  special  stress  upon  the  weight  of  the  body  as  the  main  factoi"  in  pro- 
ducing the  deformities  of  rickets,  Kehrer  (Zur  Entwickelungs-Geschichte  des  rachit. 
Beckens,  Arch.  f.  Gynaek.,  Bd.  v,  1873,  p.  55)  has  shown  that  many  of  the  changes 
characteristic  of  rickets  occur  in  congenital  cases — i.  e.,  before  the  action  of  the 
weight  of  the  trunk  is  brought  into  play.  Kehrer  refers  the  changes,  therefore,  in 
the  main,  to  muscular  action.  Fehling  (Die  Entstehung  des  rachit.  Beckens,  Arch, 
f.  Gynaek.,  Bd.  xi,  p.  173)  ascribes  the  deformities  in  rickets  to  disturbances  of 
growth  and  persistence  of  the  fetal  type.  Engel  (Wiener  med.  Wochensehrift,  1873, 
No.  40)  sought  to  prove  the  deformities  to  be  the  result  of  partially  arrested  growth. 
J.  Veit  (Die  Entstehung  der  Form  des  Beckens,  Ztschr.  fiir  Geburtsh.  and  Gynaek., 
vol.  IX,  p.  347)  furnishes  strong  evidence  in  favor  of  Litzraann's  theory. 


478 


THE  PATHOLOGY  OF   LABOR. 


(y 


Fig.  207.— Small  symmetrical  rachitic 
pelvis.    (Wood's  Museum.) 


Irregular  Racliitic  Pelves. — For  convenience'  sake  it  seems  desirable 
to  attach  to  the  description  of  the  flattened  form  the  influence  of  two 
additional  forces,  which,  upon  occasion,  operate  to  still  further  modify 
the  shape  of  the  rachitic  pelvis.  These  are  lateral  pressure  of  the 
heads  of  the  thigh-bones  at  the  acetabula  and  the  various  forms  cff  spi- 
nal curvature  which  so  commonly  result  from  rickets. 

Pressure  at  the  acetabula  is  rarely  an  operative  force,  because  rick- 
ets usually  is  developed  at  the  time  of  the  first  dentition — i.  e.,  before 

the  child  has  learned  to  walk — and  it 
is  not  until  after  the  disease  has  de- 
clined that  the  child  attempts  to  use 
its  lower  extremities.  In  the  excep- 
tional cases  in  which  the  disease  oc- 
curs later,  after  the  child  has  begun 
to  walk,  the  lateral  pressure  may  act 
in  either  one  of  two  ways : 

1.  As  a  counteracting  force  to  that 
exercised  by  the  weight  of  the  trunk, 
in  which  case  the  pelvis,  provided  the 
pathological  processes  have  only  ad- 
vanced to  a  limited  extent,  retains  a 
symmetrical  appearance,  and  resembles  closely  the  justo-minor  pelvis. 
The  rachitic  origin  is  betrayed  by  the  shape  of  the  ilia  and  the  signs 
of  rickets  in  other  parts  of  the  body.  At  the  outlet  the  antero-pos- 
terior  diameter  is  increased,  and  the  transverse  diameter  somewhat 
diminished.* 

2.  In  cases  of  excessive  softening  of  the  bones,  either  from  the  se- 
verity or  the  long  duration  of  the  disease,  the  acetabula  are  sometimes 
pushed  inward,  upward,  and 
backward,  and  the  symphysis 
pushed  forward,  so  that  the 
rami  of  the  pubes  meet  at 
an  acute  angle,  or  run  nearly 
parallel  to  one  another.  This 
lateral  compression,  in  con- 
junction with  the  rachitic 
projection  of  the  promontory, 
gives  to  the  pelvic  brim  a  tri- 
angular or  clover-leaf  shape, 
closely  resembling  the  distortion  produced  in  osteomalacia.  The  term 
pseudo-osteomalacia  given  by  Michalis  f  to  this  form  is  warranted  by 
the  existence  of  certain  features  peculiar  to  rickets,  such  as  the  small 
size  of  the  iha,  the  distance  between  the  anterior  superior  spinous 

*  ScHROEDER,  Schwangerschaft,  Geburt.  und  Woehenbett,  p.  77. 
t  MicHAELis,  Das  enge  Becken,  p.  139. 


Fig.  208.— Pseudo-osteomalacia.    (Naegele.) 


^ 


CONTRACTED  PELVES. 


479 


processes,  and  the  nature  of  the  changes  in  other  parts  of  the  bony 
skeleton.* 

In  curvatures  of  the  spine  the  shape  of  the  pelvis  is  affected,  when 
a  compensatory  scoliosis  or  kyphosis  includes  the  sacral  extremity : 

1.  In  scoliosis  (lateral  curvature)  all  the  rachitic  features  are  usu- 
ally strongly  pronounced.  The  promontory  is  tilted  to  the  side  of  the 
incurvation,  and  is  pressed  by 

the  weight  of  the  body  toward 
the  corresponding  acetabulum. 
The  ilium,  owing  to  the  in- 
creased pressure  at  the  acetabu- 
lum from  the  femur  of  the 
affected  side,  is  pushed  up- 
ward, backward,  and  inward. 
In  extreme  cases  the  approxi- 
mation of  the  promontory  to 
the  acetabulum  may  be  such  as 
to  prevent  the  entrance  of  the 
child's  head.  The  contracted 
portion  becomes,  therefore,  un- 
available for  obstetrical  pur- 
poses, f 

2.  In  kyphosis  (posterior 
curvature)  many  of  the  charac- 
teristic features  of  the  rachitic 
pelvis  are  reversed.  As  the 
upper  portion  of  the  sacrum  is 

tilted  backward,  either  the  conjugata  vera  is  increased  or  the  i^revious 
rachitic  antero-posterior  narrowing  is  greatly  diminished.  In  the 
movement  of  the  sacrum  upon  its  transverse  axis  the  lower  extremity 
is  thrown  forward,  and  the  conjugate  of  the  outlet  is  thereby  reduced. 
Kyphosis,  occurring  at  the  beginning  of  rickets,  diminishes  the  distance 
between  the  tuberosities  of  the  ischia,  but  has  little  effect  upon  the 
inferior  transverse  diameter  after  the  rachitic  changes  have  once  been 
accomj)lished. 

IXFLUEXCE    OF    THE    CONTRACTED    PeLYIS    UPOX     PrEGXAXCY    AXD 

Labor. 

The  influence  of  the  contracted  pelvis  is  not  confined  simply  to  the 
embarrassment  which  the  form  and  size  of  the  pelvis  afford  to  the 
passage  of  the  child  in  parturition ;  it  extends  to  the  production  of  a 
multitude  of  remoter  effects,  which  are  often  regarded  by  the  unin- 


FiG.  209.— Scoliosis.    (Litzmann.) 


*  The  supervention  of  true  osteomalacia  upon  rickets  has  been  observed. 
Spiegelberg,  Lehrbuch  der  Geburtshiilfe,  p.  490.) 
f  LiTZilA>'N,  Die  Formen  des  Beckens,  p.  TO. 


( Vide 


480 


THE  PATHOLOGY  OF  LABOR. 


formed  as  isolated  phenomena.  These  effects,  which  include  faulty 
positions  and  presentations  of  the  foetus,  unfavorable  shape  or  position 
of  the  uterus,  abnormal  character  of  the  pains,  and  the  like,  enter  in 
turn,  except  where  the  mechanical  difficulties  are  absolutely  insur- 
mountable, as  inportant  elements  in  the  determination  of  the  prog- 
nosis. For  our  knowledge  of  this  subject  we  are  indebted  almost 
wholly  to  the  enlightened  labors  of  the  Kiel  professors  Michaelis* 
and  Litzmann.f 

Influence  of  the  Contracted  Pelvis  upon  the  Uterus  during  Preg- 
nancy.—In  the  early  months  the  only  way  in  which  the  contracted 
pelvis  exerts  an  influence  is  in  sometimes  favoring  the  dislocation  of 
the  uterus  backward.  This  action  is  liable  to  take  place  when,  in  the 
second  or  third  mouth,  the  uterus  has  been  unusually  depressed  in 
the  pelvis,  and  the  fundus  has  swung  backward  toward  the  sacrum 
as  the  uterine  axis  approximates  to  that  of  the  pelvic  outlet.  Under 
such  circumstances  the  jutting  of  the  rachitic  promontory  is  calculated 
to  mechanically  interfere  later  with  the  ascent  of  the  organ  iuto  the 
abdominal  cavity^  in  which  case  the  pressure  of  the  inflated  intes- 
tines upon  the  anterior  aspect  of  the  uterus  pushes  the  fundus  over 
the  inclined  surface  of  the  sacrum,  and  retroversion  is  produced.  As 
the  gravid  uterus  enlarges,  owing  to'  the  limited  space  within  the  pel- 
vis the  version  gradual  passes  into  a  flexion,  which,  unless  relieved,  is 
followed  by  symptoms  of  incarceration. 

In  the  latter  months  of  gestation  the  uterus,  as  a  rule,  is  lifted  to 
a  greater  extent  above  the  pelvis  than  occurs  under  normal  conditions. 
This  elevation  is  due  to  the  growth  of  the  child,  which  is  prevented 
from  sinking  into  the  pelvis  by  the  contracted  conjugate.  Sometimes 
the  upward  tendency  of  the  uterus  is  overcome  apparently  by  the 
resistance  of  the  round  ligaments,  so  that,  while  the  head  is  retained 
at  the  brim,  the  lower  segment  hangs  empty  in  the  pelvis.  At  the 
same  time  the  uterus  possesses  an  unusual  degree  of  mobility,  in  part 
due  to  the  lack  of  fixation  afforded  by  the  descent  of  the  foetus  into 
the  pelvis,  and  in  part  to  the  laxity  of  the  abdominal  walls  and  the 
round  ligaments.  These  latter  conditions  belong,  of  course,  rather  to 
multipara  than  to  women  for  the  first  time  pregnant. 

In  close  connection  with  these  two  events,  viz.,  the  elevation  of 
the  uterus  and  its  mobility,  it  is  not  uncommon  to  observe  the  higher 
degrees  of  the  so-called  pendulous  abdomen,  caused  by  the  anteflexion 
of  the  gravid  uterus.  To  this  deformity,  furthermore,  the  small  stat- 
ure of  rachitic  patients,  the  increased  inclination  of  the  pelvis,  the 
anterior  projection  of  the  lumbar  portion  of  the  spine,  and  the  stretched 
state  of  the  abdominal  walls,  associated  often  with  separation  of  the 
recti  muscles  at  the  linea  alba,  all  contribute  their  part. 

*  Michaelis,  Das  enge  Becken,  Leipsic. 

t  LiTZMANN,  Volkraann's  Samnil.  klin.  Vortr.,"  No.  23o 


CONTRACTED  PELVES.  481 

Influence  of  the  Contracted  Pelvis  upon  the  Presentation  of  the 

Foetus. — Faulty  presentations  occur  in  contracted  pelves  more  than 
three  times  as  frequently  as  in  those  of  normal  dimensions.*  Thus, 
when,  during  the  latter  part  of  pregnancy,  the  narrow  conjugate  me- 
chanically prevents  the  head  from  sinking  into  the  pelvic  cavity,  the 
head  frequently  glides  sidewise  or  forward,  to  rest  upon  an  iliac  fossa, 
or  upon  the  upper  border  of  the  symphysis  pubis.  In  pendulous  abdo- 
men the  uterus,  in  place  of  being  inclined,  when  the  jjatient  is  in  an 
upright  position,  at  an  angle  of  thirty-five  degrees,  becomes  nearly 
horizontal,  or  may  fall  forward  so  that  the  fundus  occupies  a  deeper 
position  than  the  inferior  segment  of  the  uterus.  The  great  mobility 
of  the  uterus  admits  likewise  of  extensive  lateral  movements.  These 
combined  causes  account  for  the  lack  of  stability  in  the  foetus  and 
the  comparative  frequency  with  which  shoulder  and  breech  presenta- 
tions occur.  When  the  head  is  fixed  at  the  brim,  the  conversion  of 
tlie  vertex  into  a  brow  or  face  presentation  is  often  simply  an  exagger- 
ation of  the  normal  mechanism  of  labor  in  a  flattened  pelvis.  If  the 
head,  in  place  of  filling  the  lower  segment  of  the  uterus,  is  retained  at 
the  brim,  the  space  left  between  the  head  and  the  uterine  walls  favors 
prolapse  of  the  cord  and  extremities.  In  like  manner,  in  breech  preS' 
entations,  when  the  breech  is  detained  by  the  narrow  conjugate,  the 
feet  are  apt  to  descend  first  into  the  vagina. 

Owing  to  the  progressive  relaxation  of  the  abdominal  and  uterine 
walls  with  successive  pregnancies,  the  frequency  of  these  irregularities 
increases  nearly  in  proportion  to  the  number  of  previous  births. 

Influence  of  the  Contracted  Pelvis  upon  the  Labor-Pains.— When 
the  degree  of  pelvic  contraction  permits  the  delivery  of  the  foetus  by 
the  normal  passages  without  resort  to  embryotomy,  the  favorable  or 
iinfavorable  ending  of  the  labor  is  in  large  measure  dej^endent  upon 
the  character  of  the  pains.  Good  pains  are  of  vastly  more  consequence 
in  narrow  than  in  wide  pelves. 

Violent  pains,  where  the  mechanical  obstacles  are  insurmountable, 
either  from  the  smallness  of  the  pelvis,  the  faulty  presentation  of  the 
foetus,  the  position  of  the  child's  head,  or  its  size  and  hardness,  endan- 
ger the  integrity  of  the  uterus.  Indeed,  unless  the  mechanical  diffi- 
culties are  diminished  by  rectification  of  faulty  positions  and  presen- 
tations, or  by  embryotomy,  or  unless  relief  is  afforded  by  the  removal 
of  the  child  by  Cesarean  section,  there  is  reason  to  dread  in  such  cases 
the  occurrence  of  ruptured  uterus,  or,  after  retraction  of  the  cervix, 
that  the  uterus  may  be  torn  from  the  vagina. 

Still  more  frequently  weak  pains  are  the  cause  of  unfavorable  ter- 
minations.    Weak  pains  lead  to  lingering  labors.     Even  in  moderate 

'*  Spiegelberg  found  that,  of  544  labors  in  narrow  pelves,  the  head  presentation 
occurred  in  eighty-three  per  cent,  whereas  the  proportion  is  ninety-five  per  cent 
in  normal  pelves.     (Lehrbuch  der  Geburtshiilfe,  p.  448.) 
31 


482  THE  PATHOLOGY  OP  LABOR. 

degrees  of  coutractiou  they  fail  to  rectify  unfavorable  positions  of  the 
head  or  to  force  the  head  by  the  brim  into  the  pelvis.  Under  such 
circumstances  neither  the  forceps  nor  version  can  be  employed  without 
serious  risk,  while,  if  a  waiting  policy  is  pursued,  the  amniotic  fluid 
gradually  escapes,  and,  as  the  uterus  retracts  down  closely  upon  its 
contents,  the  foetus  perishes  from  the  gradually  increasing  hindrances 
to  the  uterine  and  placental  circulation. 

In  prolonged  labors  good  pains  alternate  at  intervals  with  those  of 
less  force.  There  is  no  standard  by  which  the  quality  of  pains  ])er  se 
can  be  determined.  The  quality  of  the  pains  is  to  be  estimated  rather 
by  the  results  which  they  accomplish.  It  may  be  stated  as  a  general 
rule,  to  which,  however,  there  are  numerous  exceptions,  that  the  strength 
of  the  pains  is  proportioned  to  the  strength  of  the  resistance  to  be  over- 
come. Strong  pains  are  on  the  Avhole  rather  more  common  in  flattened 
pelves,  and  weak  ones  in  pelves  contracted  in  all  their  diameters,  with- 
out, however,  the  rule  possessing  any  such  constancy  as  to  lead  one  to 
regard  the  form  of  the  pelvis  as  alone  possessing  any  decisive  impor- 
tance in  the  production  of  the  result.* 

In  the  first  instance,  the  character  of  labor-pains  depends  upon  the 
innervation  of  the  uterus  and  upon  the  thickness  and  integrity  of  its 
muscular  structures.  The  resistance  which  the  narrow  pelvis  offers  to 
the  expulsion  of  the  child  increases  necessarily  during  the  pains  the 
tension  and  irritation  of  the  uterine  walls ;  and  these,  corresponding  to 
the  degree  of  irritability  and  contractility  of  the  organ,  may  i3rovoke 
pains  of  unusual  violence,  which,  in  turn,  terminate,  when  the  resist- 
ance is  not  seasonably  overcome,  in  exhaustion ;  or  the  uterine  activity 
may  cease  without  any  previous  stage  of  increment ;  or,  finally,  the  ten- 
sion and  injurious  pressure  of  the  uterus  may  lead  to  local  circulatory 
disturbances,  and  to  textural  changes  which  in  themselves  weaken  the 
strength  of  the  contractions. 

Michaelis  observed  that  the  dangers  to  the  mother  and  child  grow, 
as  a  general  rule — to  which,  however,  there  are  numerous  exceptions — 
in  proportion  to  the  number  of  confinements.  The  increased  mortal- 
ity, especially  of  the  children,  he  attributed  to  a  peculiar  relaxation  of 
the  uterus  and  its  pelvic  attachments,  due  to  overexertion  in  previous 
confinements,  f  But  it  must  be  borne  in  mind  that  there  are  other 
results  of  contracted  pelves  which  directly  contribute  to  the  fatality  of 
multiparous  labors.  Thus,  we  have  seen  that  pendulous  abdomen  and 
mobility  of  the  uterus  favor  abnormal  positions  and  presentations  of 

*  Michaelis  thought  that  the  partial  pressure  of  the  promontory  and  symphysis 
excited  increased  reflex  action  of  the  uterus  in  flattened  pelves,  whereas  the  com- 
plete pressure  of  the  head  upon  the  brim  in  generally  contracted  pelves  exercised  a 
paralyzing  influence  {Joe.  cit.,  p.  185).  This  theory  has  been  called  in  question  by 
both  Spiegelberg  {he.  cit.,  p.  452)  and  Litzmann.  (Volkmann's  Samml.  klin.  Vortr., 
No.  23,  p.  177.) 

t  Michaelis,  loc.  cit.,  p.  152. 


CONTRACTED   PELVES.  483 

the  foetus,  complications  of  the  utmost  prognostic  importance ;  and, 
again,  that  the  displacements  of  the  gravid  uterus  occur  with  special 
frequency  when  the  abdominal  parietes  have  lost  their  supporting  power 
from  the  overdistention  of  previous  pregnancies.  Moreover,  when  the 
uterus  is  not  fixed  during  labor,  the  expulsive  action  of  the  abdominal 
walls  can  not  be  called  into  play,  and  thus  one  of  the  most  important 
auxiliary  forces  is  lost.  Further  sources  of  danger  lie  in  the  increased 
size  and  hardness  of  the  fetal  head  observed  in  later  pregnancies,  and 
in  the  residue  of  inflammatory  troubles  which  so  often  proceed  from 
the  first  difficult  delivery.* 

Influence  of  the  Contracted  Pelvis  upon  the  First  Stage  of  Labor.— 
At  the  beginning  of  labor  the  head  in  contracted  pelves  is  usually  re- 
tained above  the  os  internum,  while  the  lower  segment  of  the  uterus 
hangs  empty  in  the  pelvic  cavity.  As,  under  these  circumstances, 
space  is  left  between  the  head  and  the  uterine  walls,  the  entire  column 
of  amniotic  fluid  acts  directly  during  the  pains  upon  the  cervix  uteri. 
The  dilatation  of  the  cervix  takes  place  gradually,  from  above  down- 
ward, as  expansion  follows  upon  the  descent  of  the  amniotic  sac.  The 
shape  of  the  bag  of  waters  depends  upon  the  greater  or  less  degree  of 
resistance  offered  by  the  cervical  walls.  If  the  latter  are  soft  and  dis- 
tensible, the  usual  semi-globular  contour  is  maintained.  If  the  cervix 
offers  any  material  resistance,  the  membranes,  if  sufficiently  elastic, 
protrude  through  the  external  os  in  cylindrical  form.  If,  finally,  the 
chief  opposing  force  to  dilatation  is  situated  at  the  os  internum,  a  con- 
striction may  take  place  at  that  point,  while  below  the  membranes 
assume  a  spheroid  shape.  As  the  result  of  these  conditions  an  unim- 
peded, wave-like  movement  of  the  amniotic  fluid  breaks  against  the 
protruding  membranes  during  the  pains,  the  shock  of  which  is  apt  to 
produce  premature  rupture,  an  event  which  is  all  the  more  inoppor- 
tune, because  in  early  rupture  the  circumstances  all  favor  the  complete 
discharge  of  the  amniotic  fluid. 

After  the  rupture  of  the  membranes,  as  the  head  does  not  descend 
at  once  into  the  cervical  portion,  the  os  and  cervix  reclose,  though 
they  continue  dilatable  in  proportion  to  the  degree  of  distention  pre- 
viously accomplished.  Then,  as  under  the  influence  of  the  pains  the 
head  passes  into  the  pelvis,  it  gradually  once  more  unfolds  the  cer- 
vical canal,  and  completes  its  dilatation.  Should,  however,  the  head 
meet  with  any  considerable  resistance,  so  that  the  pressure  of  the 
pelvic  brim  gives  rise  to  the  formation  of  a  scalp-tumor,  the  latter 
serves  to  dilate  the  cervical  canal  and  the  os  externum.  If  the  obstacle 
U  such  as  to  prevent  the  complete  descent  of  the  head,  two  results  are 
l)ossible : 

1.  If  the  pains  continue  strong  and  no  measures  are  adopted  to 
remove  the  disproportion,  the  uterus  is  either  retracted  up  over  the 
*  Spiegelberg,  Lehrbuch  der  Geburtshiilfe,  p.  453. 


484  THE  PATHOLOGY  OF  LABOR. 

head  of  the  child  as  it  remains  above  the  brim,  until  the  overdistended 
vagina  gives  way,  in  which  case  the  laceration  occurs  in  a  transverse 
or  oblique  direction,  and  usually  upon  the  posterior  wall ;  or  the  lower 
segment  of  the  uterus  becomes  compressed  between  the  child's  head 
and  the  walls  of  the  pelvis,  and  a  thinning  and  bruising  of  the  im- 
prisoned portion  take  place.  As  the  uterus  contracts,  its  muscular 
fibers  drag  upon  the  compressed  and  weakened  tissues  at  the  fixed 
points,  which  yield  finally  to  the  tractile  force,  and  rapture  ensues. 

2.  If  the  pains  are  weak  or  fail  outright,  the  lower  segment  of  the 
uterus  remains  undilated  until  either  strong  pains  are  excited  or  the 
mechanical  hindrance  is  so  far  removed  by  perforation  of  the  head 
that  the  weakened  pains  suffice  to  overcome  the  obstacle. 

Influence  of  the  Contracted  Pelvis  upon  the  Mechanism  of  Labor.— 
When  the  pelvic  contraction  is  not  such  as  to  render  the  entrance  of 
the  head  impossible,  the  mechanism  of  labor  depends  not  only  upon 
the  size  and  shape  of  the  pelvic  space,  but  upon  the  size,  form,  com- 
pressibility, and  position  of  the  child's  head.  If  a  small,  soft  head  has 
to  pass  through  a  pelvis  contracted  to  only  a  moderate  degree,  the 
mechanism  may  not  differ  from  that  of  a  normal  labor.  In  cases  of 
relatively  great  disproportion,  delivery  is  only  practicable  where  the 
position  of  the  head  is  favorable — i.  e.,  corresponds  in  each  case  to  the 
peculiar  shape  of  the  pelvis.  If  the  conditions  are  favorable,  and  the 
pains  are  of  normal  strength,  a  segment  of  the  head,  after  the  period 
of  dilatation  has  been  completed,  is  pressed  into  the  pelvis.  The  size 
of  the  segment  depends  upon  the  extent  of  the  resistance  offered,  and 
thus,  at  an  early  stage,  it  :^urnishes  us  a  notion  as  to  the  degree  of  dis- 
proportion existing.  As  labor  progresses,  the  cranial  bones  change  in 
shape  and  overlap  one  another,  so  that  the  head  gradually  becomes 
molded  to  the  contour  of  the  pelvic  ring.  When  the  largest  circum- 
ference of  the  child's  head  has  become  fixed  at  the  pelvic  strait,  as  the 
contraction  exists  for  the  most  part  at  the  brim,  the  difficulties  are 
usually  overcome ;  and,  where  the  pains  continue  good,  the  remainder 
of  the  labor  is  accomplished  in  accordance  with  the  ordinary  mechan- 
ism. If  the  pains  fail,  or  the  contraction  continues  throughout  the 
entire  pelvic  canal,  artificial  aid  may  be  needed  even  after  the  brim  has 
been  passed. 

In  the  simple  flattened  pelvis  the  occipito-frontal  diameter  of  the 
head  engages  in  the  transverse  diameter  of  the  brim.  Even  when 
the  position  is  originally  oblique,  the  intermittent  contractions  of  the 
uterus  communicate  movements  to  the  smooth  surface  of  the  head, 
which  gradually  bring  its  long  diameter  into  correspondence  with  the 
long  diameter  of  the  flattened  pelvis.  The  head  enters  the  brim  with 
Its  posterior  surface  tilted  toward  the  shoulder,  the  anterior  parietal 
bone  presenting,  and  the  sagittal  suture  running  parallel  with,  and  in 
more  or  less  close  proximity  to,  the  promontory.     This  lateral  obliqui- 


CONTRACTED  PELVES.  485 

ty,  or  obliquity  of  Naegele  as  it  is  termed,  is  due  simj^ly  to  the  fact 
that  the  narrowing  of  the  antero-posterior  diameter  prevents  both 
parietal  bones  from  entering  the  pelvis  upon  the  same  plane.  When 
the  broad  region  between  the  parietal  bosses  meets  with  the  resistance 
of  the  conjugate,  the  occipital  portion  of  the  head  glides  to  one  side, 
and  the  narrow  bitemporal  diameter  engages  in  the  contracted  space. 
In  this  position  the  occiput  usually  rests  upon  the  linea  terminalis. 
Owing  to  the  resistance  ofEered  to  the  occiput,  the  forehead  sinks  into 
the  pelvis,  so  that  the  large  fontanelle  occupies  a  deeper  position  than 
the  posterior  one. 

Before  the  head  adapts  itself,  therefore,  to  the  pelvic  entrance,  the 
anterior  parietal  surface  rests  upon  the  symphysis,  while  the  posterior 
surface  is  impinged  upon  by  the  promontory  near  the  large  fontanelle. 
The  latter  is  felt  low  down,  near  the  median  line.  The  small  fonta- 
nelle, owing  to  the  dip  of  the  forehead,  is  occasionally  out  of  reach. 
Upon  the  side  of  the  pelvis  to  which  the  forehead  is  turned,  the  space 
is  incompletely  filled  out. 

Tlie  adaptation  of  the  head  to  the  pelvic  brim  is  the  result  of  two 
combined  movements,  which  occur  nearly  simultaneously  : 

1.  The  symphysis  pubis  furnishes  a  pivot  around  which  the  head 
rotates  in  the  direction  of  the  fronto-occipital  diameter.  As  the  head 
is  pressed  into  the  pelvis  from  above,  the  posterior  parietal  bone  is 
flattened  by  the  projecting  promontory.  During  the  descent  the  dis- 
tance between  the  sagittal  suture  and  the  promontory  gradually  widens, 
and  the  former  approaches  the  median  line. 

2.  We  have  seen  that  the  head  entered  the  pelvis  at  first  with  a  deep 
position  of  the  anterior  fontanelle.  By  the  time,  however,  the  bitem- 
poral diameter  becomes  fairly  fixed  in  the  conjugate,  the  anterior  fon- 
tanelle moves  upward  and  forward  toward  the  side  wall  of  the  pelvis, 
while  the  small  fontanelle  sinks  downward,  and  occupies  a  position 
near  the  center  of  the  cavity.  This  movement  is  not  simply  a  crowd- 
ing of  the  entire  head  in  the  direction  of  the  brow,  but  is  due  to  a 
rotation  of  the  head  upon  an  axis  furnished  by  the  conjugate  diam- 
eter,* the  symphysis  and  the  promontory  furnishing  the  pivotal  points. 

By  the  time,  in  the  rotation  of  the  head  upon  its  fronto-occipital 
diameter,  the  posterior  boss  reaches  the  level  of  the  promontory,  the 
largest  circumference  of  the  child's  head  has  already  engaged  in  the 
straitened  brim,  and  the  influence  of  the  pelvic  flattening  upon  the 
mechanism  of  labor  ceases.  Then,  if  the  pains  continue  good,  the 
flexed  head  reaches  the  floor  of  the  pelvis,  the  occiput  rotates  to  the 
front,  and  delivery  is  accomplished  as  under  normal  conditions. 

In  the  justo-minor  pelvis,  the  mechanism  of  labor  is  nearly  the 
reverse  of  that  described  in  the  flattened  form.  Thus,  as  a  rule, 
both  parietal  bones  engage  in  the  pelvic  brim  at  the  same  time — i.  e., 
*  LiTZMANN,  Volkmann's  Samml.  klin.  Vortr.,  No.  74,  p.  557. 


436  THE  PATHOLOGY  OF  LABOR. 

the  obliquity  of  Naegele  is  either  slightly  marked  or  absent  altogether. 
Again,  the  head  may  enter  the  pelvis  in  any  of  its  diameters.  To  be 
sure,  the  oblique  diameter  is  the  one  it  usually  occupies.  Still,  Litz- 
mann  reports  two  cases  in  which  the  sagittal  suture  corresponded  to 
the  conjugate  diameter  from  the  outset  of  the  labor.*  In  the  early 
stao-es,  it  is  not  uncommon  for  the  head  to  oscillate  at  the  brim  for 
a  time  before  fixation  takes  place. 

Characteristic  of  transverse  narrowing  is  the  flexed  condition  of 
the  head  from  the  moment  it  begins  its  descent  into  the  pelvis.  In- 
deed, the  flexion  at  the  brim  equals  in  degree  that  which  usually  ob- 
tains only  at  the  pelvic  outlet.  The  small  fontanelle  occupies  the 
middle  point  of  the  pelvic  space,  the  neck  rests  upon  the  linea  termi- 
nalis,  the  anterior  portion  of  the  head  and  brow  are  pressed  against 
the  opposite  pelvic  walls,  the  long  diameter  of  the  head  (from  chin  to 
vertex)  lies  in  the  axis  of  the  pelvis,  and  the  face  looks  upward  toward 
the  fundus  uteri.  If  the  transverse  narrowing  continues  toward  the 
outlet,  the  extreme  flexion  is  maintained  after  the  brow  has  passed 
below  the  level  of  the  promontory.  In  such  cases  it  may  even  happen 
that  the  small  fontanelle  may  make  its  appearance  at  the  frenulum 
in  place  of  turning  under  the  arch  of  the  pubes.  Sometimes  the  head 
gets  fairly  impacted  in  the  pelvis,  and  further  advance  is  rendered  im- 
possible. When  the  pelvis  widens  below  the  brim,  the  small  fontanelle 
noticeably  leaves  little  by  little  its  central  position. 

In  the  generally  contracted,  flattened  pelvis,  the  mechanism  of 
labor  is  influenced  by  both  the  antero-posterior  and  transverse  short- 
ening. As  in  flattened  pelves,  the  head  usually  occupies  the  transverse 
diameter,  and  the  sagittal  suture  looks  backward  toward  the  promon- 
tory. Before  the  head  becomes  fixed,  it  often  balances  at  the  conju- 
gate, rocking  to  and  fro,  as  the  uterus  falls  from  the  one  side  to  the 
other.  For  a  time,  therefore,  the  position  of  the  fontanelles  varies 
with  that  of  the  woman.  If,  however,  the  disproportion  is  not  abso- 
lute, and  the  pains  suffice  finally  to  fix  the  head,  the  latter  usually 
becomes  strongly  flexed,  and  the  occiput  descends  first  into  the  pelvis. 

When  the  head  does  not  enter  the  contracted  pelvis  in  an  advan- 
tageous position,  and  the  fault  is  not  rectified  either  by  the  hand  or 
the  action  of  the  labor-pains,  delivery  of  the  child  without  perforation 
often  becomes  impossible.  The  most  dangerous  of  these  faulty  posi- 
tions are : 

1.  Cases  in  which  the  lateral  obliquity  of  Naegele  is  exaggerated, 
so  that  the  presenting  part  is  formed  by  the  anterior  parietal  bone. 
The  more  striking  forms  usually  occur  in  pelves  with  an  extremely 
narrow  conjugate  and  a  high  promontory.  The  former  maintains 
the  head  high  above  the  brim,  while  the  latter  imparts  to  the  uterus 
a  posterior  concavity.     As  the  uterine  curve  is  followed  by  the  axis  of 

*  LiTZMANN,  Volkmann's  Samml.  klin.  Vortr.,  No.  74,  p.  545. 


CONTRACTED  PELVES.  4S7 

the  foetus,  the  head  is  strongly  bent  toward  the  jDosterior  shoulder. 
Sometimes  iu  presentations  of  the  anterior  parietal  bone  the  sagittal 
suture  lies  above  the  j^romontory,  and  an  ear  can  be  left  just  behind 
the  sympyhsis. 

2.  Cases  in  which  the  pelvic  brim  is  covered  by  the  posterior  pari- 
etal bone.  The  sagittal  suture  is  then  directed  to  the  front,  some- 
times lying  even  above  the  sujierior  border  of  the  anterior  pelvic  wall. 
Near  the  promontory  the  squamous  suture,  and  at  times  the  ear,  can 
be  felt.  This  peculiarity  is  rare  in  other  forms  of  contracted  pelves, 
but  occurs  as  often  as  once  in  five  times  (Litzmann)  in  flattened  pelves 
with  coincident  shortening  of  the  transverse  diameter, 

3.  In  cases  of  well-marked  kidney-shaped  pelves,  the  head  mav 
engage  in  one  side  of  the  pelvis  only.  The  occiput  then  enters  usually 
the  side  of  the  brim  to  which  the  back  of  the  child  is  turned. 

4.  Brow  and  face  presentations  are  simply  exaggerations  of  the 
anterior  dip  of  the  head,  which  we  have  seen  is  the  normal  mode  of 
descent  during  the  early  stage  of  labor  in  flattened  pelves.  Although 
not  peculiar  to  contracted  pelves,  they  should  always,  when  present, 
lead  to  careful  measurements  of  the  pelvic  diameters.  They  increase 
the  difficulties  of  delivery,  not  only  because  of  the  unfavorable  rela- 
tions of  the  diameters  of  the  head  to  those  of  the  pelvis,  but  because 
the  pelvic  deformity  interferes  with  the  proper  rotation  of  the  chin 
and  forehead  forward  under  the  arch  of  the  pubes. 

In  breech  presentations,  the  delivery  of  the  trunk  takes  place  in 
accordance  with  the  ordinary  mechanism  in  the  normal  pelvis.  The 
arms,  however,  are  more  liable  to  be  reflected  to  the  sides  of  the  head. 

In  flattened  pelves  the  after-coming  head  enters  the  brim  in  the 
transverse  diameter.  The  position  of  the  chin,  where  the  transverse 
space  is  ample,  varies  with  the  degree  of  conjugate  shortening.  Where 
the  latter  is  only  of  moderate  extent,  the  ordinary  flexion  of  the  head 
may  not  be  interfered  with.  If,  however,  the  disproportion  between 
the  head  and  pelvic  diameters  is  considerable,  partial  extension  takes 
place.  In  cases  of  extreme  contraction  the  entire  head  may  be  retained 
at  the  brim.  The  chin  is  then  usually  turned  forward  so  as  to  rest 
upon  one  of  the  pubic  rami,  while  chin  and  occiput  occupy  nearly  the 
same  level. 

In  breech  deliveries,  the  mechanism  of  the  head's  jjassage  through 
simple  flattened  pelves  varies  as  the  head  engages  in  a  state  of  flexion 
or  extension.  In  the  former  case,  while  the  anterior  parietal  bone 
moves  downward  over  the  symphysis,  the  transit-line  marked  by  the 
promontory  upon  the  posterior  parietal  bone  runs  from  its  anterior 
inferior  angle,  just  in  front  of  the  ear,  in  an  oblique  direction  upward 
toward  the  parietal  boss.  "When,  however,  the  head  enters  the  pelvis 
in  a  state  of  partial  extension,  a  furrow  is  formed  by  the  promontory, 
which  runs  nearly  parallel  to  the  coronal  suture.     If,  finally,  the  ex- 


i88 


THE  PATHOLOGY  OF  LABOR. 


tension  is  complete,  and  the  occiput  descends  first  into  tlie  pelvis, 
the  marking  of  the  promontory  is  found  between  the  boss  and  the 
lambdoidal  suture. 

In  pelves  contracted  in  the  transverse  diameter,  extension  of  the 
chin,  unless  the  contraction  be  slight,  proves  an  insuperable  obstacle 
to  delivery.  Flexion,  however,  is  the  rule,  as  the  resistance  which  the 
occiput  meets  with  from  the  walls  of  the  pelvis  tends  to  direct  the 
chin  toward  the  chest. 

The  Effects  produced  in  Contracted  Pelvis  by  the  Pressure  of  the 
Child  upon  the  Soft  Maternal  Tissues.— The  body  of  the  child  rarely, 
and  only  in  cases  of  extreme  prolongation  of  the  expulsive  period, 
leaves  any  traces  upon  the  maternal  soft  parts.  Injurious  pressure 
proceeds  almost  exclusively  from  the  child's  head.  As  the  intrapel- 
vic  organs  sustain  excessive  pressure  when  of  short  continuance  more 
easily  than  that  which  is  moderate  but  prolonged,  the  most  striking 
lesions  are  produced  in  head  presentations.  The  after-coming  head 
usually  passes  through  the  pelvis  too  rapidly  to  produce  any  pro- 
nounced effects.  The  pressure  is,  as  a  rule,  most  marked  at  the  brim, 
where,  as  we  have  seen,  the  contraction  is  in  the  generality  of  cases 
greatest,  and  where  the  pelvic  canal  is  most  encroached  upon  by 
shuYY)  projections.  The  pressure  may  be  either  diffused  over  the  entire 
periphery  of  the  brim,  or  it  may  be  more  localized  at  certain  definite 
points. 

Diffused  jiressure  occurs  in  justo-minor  jx^lves,  or  where  complete 
accommodation  of  the  child's  head  to  the  form  of  the  pelvis  takes 
place.  It  gives  rise  to  disturbed  circulation  in  the  hypogastric  veins, 
and  as  a  further  consequence  to  transudation  of  serum,  and  capillary 
hfemorrhages  in  the  tissues  of  the  cervix,  the  vaginal  walls,  and  exter- 
nal organs  of  generation. 

Circumscribed  pressure  leads  to  crushing,  thinning,  and  at  times  to 
the  comjDlete  destruction  of  the  tissues  acted  upon,  the  extent  of  the 
lesion  depending  upon  the  intensity  and  duration  of  the  force  exerted. 
Usually  the  destructive  action  proceeds,  following  the  direction  of  the 
pressure  from  within  outward — i.  e.,  the  injuries  are  more  consider- 
able, both  in  degree  and  extent,  in  the  tissues  next  to  the  child's  head 
than  in  the  deeper  ones  contiguous  to  the  pelvic  border.  Complete 
perforation  of  the  tissues  during  labor  is  rare.  Perforation  is  com- 
monly the  result  of  necrosis,  the  sloughing  of  the  compressed  tissues 
taking  place  during  the  puerperal  period. 

The  pressure  from  the  promontory  is  brought  to  bear,  with  rare  ex- 
ceptions, upon  the  cervix  uteri.*     The  supravaginal  portion  is  more 

*  LiTZMANN,  Volkraann's  Samml.  klin.  Vortr.,  No.  23,  p.  186.  An  exceptional 
instance  of  pressure  ending  in  perforation  of  the  posterior  vaginal  wall  has  been 
reported  by  Hofmeier  (Zur  Casuistik  des  Stachelbeckens,  Ztschr.  fur  Geburtsh.  und 
Gynaek.,  vol.  x,  pp.  5,  6). 


CONTRACTED  PELVES.  489 

commonly  affected  than  the  vaginal  portion.  The  consequent  loss  of 
substance  is  of  a  funnel  shape,  starting  from  the  inner  surface,  and 
rarely  penetrating  through  the  peritonceum.  The  coverings  of  the 
promontory  are  not  affected  by  pressure. 

Pressure  from  the  upper  border  of  the  symphysis  pubis  usually 
affects  the  vaginal  Avail  and  the  adjacent  tissues  of  the  bladder.  Fis- 
tulae  resulting  are  therefore  much  more  commonly  vesico- vaginal  than 
utero-vesical.  Here,  too,  the  lesions  are  more  extensive  upon  the  inner 
surface  of  the  utero-vaginal  canal,  and  diminish  as  they  extend  out- 
ward. Thus,  the  destruction  of  tissue  is  greatest  upon  the  cervical  and 
vaginal  walls,  is  less  marked  upon  the  posterior  bladder  wall,  while  the 
anterior  wall  exhibits  only  faint  traces  of  injury. 

Pressure  from  the  lateral  walls,  and  from  the  horizontal  rami  of  the 
pubes,  occurs  most  frequently  in  faulty  positions  of  the  child's  head. 
Tlius,  in  brow  presentations,  the  intervening  tissues  are  apt  to  become 
clamped  between  the  occiput  and  the  margin  of  the  side  wall.  Again, 
when  the  sagittal  suture  is  directed  to  the  front,  and  the  posterior 
parietal  bone  presents,  a  similar  compression  may  take  place  between 
the  anterior  wall  and  the  child's  head.  Sharp  bony  projections  from 
the  crests  of  the  pubes  are  commonly  covered  by  the  tendinous  attach- 
ments of  the  psoas  minor  muscles.  In  case  of  long-continued  labor, 
however,  the  spinous  outgrowths  and  sharp  edges  of  the  crests  are 
liable  to  rub  through  their  protective  coverings,  and  secondarily  the 
utero-vaginal  tissues. 

Influence  of  the  Pressure  of  the  Pelvis  upon  the  Integuments  of  the 
Child's  Head. — One  of  the  commonest  results  of  the  peripheral  pressure 
of  the  brim  upon  the  child's  head  is  the  production  of  the  scalp-tumor. 
Its  formation  is  usually  associated  with  compression  of  the  cranial 
bones.  As  the  bones  overlap,  the  integuments  of  the  engaged  portion 
of  the  head  are  thrown  into  folds.  As,  however,  in  consequence  of 
the  obstruction  in  the  venous  circulation,  transudation  of  serum  takes 
place  into  the  subcutaneous  cellular  tissue,  the  folds  subsequently  dis- 
appear, and  a  swelling  ensues.  It  will  be  seen  that  conditions  favor- 
able to  the  production  of  the  scalp-tumor  are  a  soft,  easily  molded 
head,  and  such  degree  of  transverse  pelvic  contraction  as  serves  to 
render  the  circular  pressure  of  the  scalp  complete.  Owing  to  the  lat- 
ter condition,  the  scalp-tumor  is  found  more  frequently  and  more  de- 
veloped in  justo-minor  and  generally  contracted  flattened  pelves  than 
in  simple  flattened  pelves  with  normal  transverse  dimensions.  Usually 
the  tumor  does  not  form  until  after  rupture  of  the  membranes.  At 
times,  however,  in  justo-minor  pelves  the  head  may  become  so  fixed 
at  the  brim  during  the  first  stage  of  labor  that  a  diffused  swelling  of 
the  scalp  may  follow  while  the  membranes  are  still  intact.  A  scalp- 
tumor  at  the  brim  is  of  favorable  import.  It  shows  that  the  pains  are 
good.     So  long  as  the  tumor  continues  to  increase,  if  the  presentation 


490  THE   rATIIOLOGY   OF   LABOR. 

is  favorable,  the  aceommodatiou  of  the  head  remains  a  possibility. 
The  increase  of  the  tumor  serves,  too,  to  fix  the  head  at  the  brim,  and 
favors  the  overlapping  of  the  cranial  bones.  It  likewise  gives  to  the 
head  the  form  of  an  elongated  ellipse,  a  form  most  favorable  to  its 
passage  through  the  contracted  pelvic  canal. 

Localized  pressure-marks  upon  the  child's  head  are  derived,  in  the 
great  majority  of  cases,  from  contact  with  the  promontory.  With  less 
frequency  they  have  their  origin  in  pressure  produced  by  the  anterior 
and  lateral  pelvic  walls  and  the  inward  projection,  in  rachitic  pelves, 
of  the  cartilage  at  the  symphysis  pubis.  They  consist  of  round  and 
oval  spots  and  reddened  lines,  which  disappear  in  the  ligliter  cases 
usually  in  from  twelve  to  twenty-four  hours.  If  the  pressure  has  been 
long  continued,  it  may  give  rise  to  ulceration,  or  even  to  complete 

destruction  of  the  skin  down  to  the 
periosteum.  While  not  usually  danger- 
ous to  the  child,  in  exceptional  cases 
they  may  become  the  starting-point  of 
suppuration  in  the  surrounding  subcu- 
taneous cellular  tissue,  and  thus  lead  to 
fatal  pyaemia.  They  are  found  with 
greatest  frequency  upon  the  parietal 
bones,  especially  ujDon  the  posterior  one. 

FIG.  210.-Pressure^mark  upon  skull,      jy^^^.^     ^,^^^^^     ^|^gy      ^^.^     situatcd     UpOU 

the  frontal,  and  in  very  rare  instances, 
finally,  upon  the  occipital  and  temporal  bones.  The  situation  and 
direction  of  the  red  lines  depend  chiefly  upon  the  manner  in  which 
the  head  enters  the  pelvis.  Thus,  in  simple  flattened  pelves,  where 
moderate  extension  occurs  in  the  normal  mechanism  of  labor,  the 
mark  of  the  promontory  runs  along  the  posterior  parietal  bone,  between 
the  boss  and  the  large  fontanelle,  either  parallel  to  the  coronal  suture, 
or  at  first  in  the  direction  of  the  boss,  and  then  later  as  flexion  occurs 
forward  toAvard  the  frontal  bone  (Dohrn).  In  cases  where  transverse 
shortening  causes  flexion  of  the  head  at  the  brim,  the  principal  point 
of  pressure  lies  near  the  parietal  boss,  and  the  line  runs  obliquely  for- 
Avard  toAvard  the  outer  angle  of  the  eye,  or  toAvard  the  cheek,  accord- 
ing to  the  extent  of  the  flexion.  Sometimes  a  red  line  running  across 
the  forehead,  nearly  parallel  to  the  coronal  suture,  is  produced  by 
the  pressure  of  the  side  Avail. 

Pressure  upon  the  ophthalmic  vein,  Avhen  it  occurs,  leads  to  cedem- 
atous  SAvelling  and  hyperemia  of  the  lid,  and  to  increased  secretion 
from  the  conjunctiA'a. 

Influence  of  the  Pressure  of  the  Pelvis  upon  the  Cranial  Bones.— 
The  so-called  molding  of  the  child's  head,  by  Avhich  it  is  made  to  con- 
form to  the  size  and  shape  of  the  pelvis,  is  chiefly  effected  by  the  dis- 
placements and  alterations  in  the  form  of  the  cranial  bones.     Of  the 


CONTRACTED   PELVES.  491 

displacements,  the  most  important  consists  iu  the  overriding  of  the 
bones  at  the  principal  sutures.  The  most  common  site  is  along  the 
sagittal  suture.  Usually  the  posterior  parietal  bone  is  flattened  and 
depressed  beneath  its  fellow.  At  the  same  time  the  curvature  of  the 
anterior  or  presenting  parietal  bone  is  increased.  In  transverse  nar- 
rowing, the  occipital  bone  is  depressed  along  the  lambdoidal  suture. 
The  position  of  the  frontal  bones  at  the  coronal  suture  is  subject  to  a 
variety  of  influences.  As  a  rule,  however,  they  are  dej^ressed  beneath 
the  parietal  bones.  Overlapi^ing  often  does  not  extend  the  entire 
length  of  a  suture,  but  may  exist  in  one  jjart,  while  in  another  the 
bones  may  occupy  the  same  level.  Sometimes  a  displacement  takes 
place  between  the  two  lateral  halves  of  the  head  in  the  direction  of 
the  occipito-frontal  diameter.  This  movement  is  supposed  to  be  due 
to  the  influence  of  the  promontory,  which  pushes  the  posterior  half 
forward  when  the  head  is  flexed,  and  backward  in  cases  of  partial 
extension. 

The  compression  to  which  the  child's  head  is  subjected,  when  pro- 
longed and  excessive,  is  apt  to  produce  disturbed  cranial  circulation. 
Rupture  of  the  capillaries  which  pass  from  the  surface  of  the  brain  to 
the  arachnoid  sac,  and  to  the  sinuses  of  the  dura  mater,  may  give  rise 
to  intracranial  extravasations.  The  overriding  at  the  sagittal  suture, 
in  extreme  cases,  may  cause  laceration  of  the  sinus  longitudinalis. 
Separation  of  the  bones  at  the  sagittal  and  coronal  sutures  sometimes 
takes  place  while  the  coverings  of  the  skull  remain  intact.* 

In  a  small  jiercentage  of  cases  (7'3  per  cent,  Litzmann)  furrow-like 
depressions  occur.  The  usual  site  is  along  the  line  of  the  coronal 
suture,  where  they  are  formed  by  the  promontory.  In  front  a  grooved 
line  is  sometimes  found  near  the  squamous  suture,  produced  by  the 
pressure  of  the  anterior  pelvic  wall.  Triangular  depressions  (the 
spoon -shaped  depressions  of  Michaelis)  situated  upon  the  posterior 
parietal  bone,  between  the  boss  and  the  large  fontanelle,  are  of  still 
rarer  occurrence.  They  are  found  chiefly  upon  the  heads  of  prema- 
ture children,  where  they  are  of  sinister  import.  Actual  fracture  of 
the  skull  in  head  presentations  is  extremely  infrequent,  and  is  gener- 
ally due  to  the  employment  of  the  forceps. 

In  breech  presentations,  lesions  of  the  scalp,  owing  to  the  shortness 
of  the  time  to  which  the  after-coming  head  is  subject  to  the  pressure 
of  the  contracted  pelvis,  are,  in  two  thirds  of  the  cases,  absent  alto- 
gether. When  they  are  present  they  are  comparatively  trivial,  con- 
sisting of  slight  swelling  of  the  integuments,  and  now  and  then  of  a 
red  mark  left  by  the  promontory.  The  cranial  bones,  on  the  con- 
trary, when  rapidly  dragged  by  the  projecting  promontory,  are  pecul- 
iarly liable  to  serious  injury.  Thus,  in  breech  cases,  depressions,  fract- 
ures, and  fissures  of  the  parietal  bones  are  much  more  common  than 
*  LiTZ.MAXN,  Volkmann's  Saraml.  klin.  Vortr.,  No.  23,  p.  191. 


492  THE  PATHOLOGY  OP  LABOR. 

in  head  presentations.  Forcible  tractions  upon  the  trunk  sometimes 
lead  too  to  a  rupture  of  the  squamous  sutures,  or  even  to  separation  of 
the  condyles  from  the  occipital  bones.* 

Prognosis  in  Contracted  Pelves.— The  mortality  to  the  mother  is  at 
least  twice  as  great  as  in  normal  pelves.  The  causes  of  this  increased 
death-rate  are  to  be  found  in  the  concurrent  action  of  a  great  variety 
of  influences.  Among  the  chief  of  these  is  the  prolonged  labor,  an 
event  which  under  all  circumstances,  especially  after  the  rupture  of 
the  membranes,  tends  to  diminish  the  chances  of  recovery.  This  re- 
sult is  due  to  the  strain  upon  the  nervous  system  from  the  protracted 
duration  of  the  associated  pain,  to  the  depression  of  the  vital  powers 
growing  out  of  the  fasting  and  loss  of  sleep  which  labor  entails,  to  the 
irritation  and  crushing  of  the  soft  parts,  and,  finally,  to  decomposition 
of  the  fluids  retained  within  the  uterine  cavity  in  cases  where  access 
of  air  has  taken  place.  In  contracted  pelves  we  have  superadded  to 
these  general  sources  of  disturbance  the  special  injurious  effects  pro- 
duced by  the  pressure  of  the  lower  segment  of  the  uterus,  the  vagina, 
and  the  soft  parts  which  cover  the  cavity  of  the  small  pelvis  between 
the  hard  head  of  the  child  and  the  bony  walls.  As  the  results  of 
pressure,  we  have  seen  that  obstruction  to  the  venous  circulation, 
oedema,  capillary  haemorrhages,  superficial  lacerations  of  the  mucous 
membrane,  and  at  localized  points  necrosis  and  even  complete  separa- 
tion of  the  interposed  tissue  may  take  place.  These  further  lead  to 
metritis,  endometritis,  parametritis,  and  perimetritis,  which  are  an- 
nounced at  times  during  labor,  but  more  commonly  subsequent  to 
confinement,  by  sharp  elevations  of  temperature.  When  the  destruc- 
tion of  tissue  reaches  the  peritonaeum,  general  peritonitis  follows,  as 
a  rule.  When  the  necrosed  tissues  become  gangrenous  from  access 
of  air,  the  septic  poisons  generated  spread  through  the  cellular  tissue, 
and  lead  speedily  to  a  fatal  termination.  Sometimes  shock  destroys 
the  patient  during  the  first  day  or  two  following  labor,  before  local  in- 
flammations have  had  time  to  develop.  Further  dangers  to  be  appre- 
hended are  rupture  of  the  uterus  and  the  pelvic  articulations,  fistulous 
communications  with  the  bladder  and  the  rectum,  injuries  to  nerves 
of  the  ischiatic  plexus,  post-partum  haemorrhage  as  a  consequence  of 
uterine  exhaustion,  and  thrombus  formation  in  the  veins  of  the  uter- 
ine parenchyma.  Even  the  operative  measures  resorted  to  for  the 
relief  of  the"  patients  are  often  new  sources  of  peril,  and  their  employ- 
ment is  to  be  regarded  simply  as  a  lesser  evil. 

For  the  child  the  action  of  the  contracted  pelvis  is  even  more  del- 
eterious, f     The   infant   mortality,   in   cases   not   requiring   sacrificial 

*  C.  RuGE,  Verletzung  des  Kindes  diirch  Extraction  bei  Beekenlage,  Ztschr.  f. 
Geburtsh.,  Bd.  i,  p.  74. 

+  Spiegelberg  puts  the  mortality  of  the  children  at  thirty-five  per  cent  {vide  Lehr- 
buch  der  Geburtshiilfe,  p.  464). 


TREATMENT  OF  CONTRACTED  PELVES.  493 

operations,  is  explained  by  the  long  duration  of  the  labor  and  the 
prevalence  of  faulty  presentations  and  positions.  In  the  majority  of 
instances  death  takes  place  from  asphyxia  promoted  by  the  early  rupt- 
ure of  the  membranes,  the  complete  escape  of  the  amniotic  fluid,  the 
prolapse  of  the  cord,  the  disturbances  in  the  utero-placental  circula- 
tion resulting  from  the  retraction  of  the  nterus  upon  the  surface  of 
the  child's  body,  and  sometimes  by  the  premature,  separation  of  the 
placenta.  The  prognosis  for  the  child  is  especially  unfavorable  in 
premature  labors.  This  arises  not  alone  from  the  increased  frequency 
of  malpresentations,  but  from  the  diminished  power  of  premature 
children  to  resist  external  pressure.  Thus,  death  may  take  place  from 
direct  pressure  upon  the  medulla  oblongata  through  the  thin  bony 
coverings  of  the  head,  or  extensive  cerebo-spinal  effusions  of  blood 
may  result  from  the  laceration  of  the  delicate  walls  of  the  intracranial 
and  intraspinal  vessels. 


CHAPTER  XXVI. 

TREATMENT  OF  CONTRACTED  PELVES. 

Cases  of  extreme  pelvic  contraction,  rendering  delivery  per  vias  natwales  impossi- 
ble.— Cases  indicating  craniotomy  or  premature  labor. — Cases  where  extraction 
of  a  living  child  at  term  is  possible. — Premature  labor. — Version. — Forceps. — 
Expectant  treatment. 

The  resources  at  the  disposition  of  the  accoucheur,  in  cases  of  con- 
tracted pelvis  requiring  obstetrical  aid,  are  the  Caesarean  section,  the 
induction  of  premature  labor,  craniotomy,  forceps,  and  version.  But, 
before  it  is  possible  to  form  an  opinion  regarding  the  treatment  best 
suited  to  an  individual  case,  it  is  necessary  to  first  obtain  a  clear  and 
definite  idea  regarding  the  degree  and  character  of  the  pelvic  deform- 
ity. We  have,  then,  to  settle  the  followiug  questions  :  Has  pregnancy 
advanced  to  term?  If  not,  does  the  case  call  for  the  induction  of 
abortion  or  premature  labor  ?  If  the  end  of  utero-gestation  has  been 
reached,  is  it  possible  to  deliver  the  child  through  the  natural  passages? 
Is  the  child  living  or  dead?  If  the  former,  do  the  interests  of  the 
mother  require  the  sacrifice  of  the  child's  life  ?  If  the  conditions  are 
such  as  not  to  render  it  impossible  for  a  living  child  to  be  born,  in 
what  way  can  we  best  subserve  the  interests  of  both  mother  and  child  ? 
The  right  choice  of  measures  requires  not  only  an  accurate  apprecia- 
tion of  the  advantages,  limitations,  and  drawbacks  which  inhere  to  the 
measures  themselves,  but  the  extent  to  which  the  mechanical  obsta- 
cles to  delivery  are  heightened  or  modified  by  those  remoter  influences 
which  we  have  seen  are  exerted  upon  the  organic  processes  of  labor  by 
the  pelvic  contraction.  , 


^94  THE  PATHOLOGY   OF   LABOR. 

The  greater  the  degree  of  pelvic  narrowing,  however,  the  more  cle« 
cided  the  influence  of  the  pelvis  becomes,  and  the  more  definite,  there- 
fore, the  treatment. 

For  the  sake  of  convenience  it  is  customary  to  consider  apart  the 
following  classes :  * 

1.  Cases  of  such  extreme  23elvic  contraction  that  the  attempt  to  de- 
liver the  child  through  the  natural  passages  is  inadvisable.  In  these 
extreme  degrees  of  pelvic  deformity  premature  labor  holds  out  no  hope 
of  saving  the  life  of  the  child,  and  affords  but  a  trifling  advantage  to 
the  motlier.  If  abortion  is  not  produced  in  the  early  mouths,  the  only 
resource  is  the  Cesarean  section  or  laparo-elytrotomy.  The  precise 
limit  at  which  the  dangers  from  delivery  through  the  pelvis  rise  to  the 
level  of  or  exceed  those  from  the  Cesarean  section  is  not  easy  to  deter- 
mine. It  depends  partly  upon  the  size  and  ossification  of  the  child's 
head,  and  largely  upon  the  experience  and  dexterity  of  the  operator. 

Michaelis,  in  the  case  of  a  dwarf  scarcely  three  and  a  half  feet 
high,  extracted  a  small  child  through  a  pelvis  measuring  but  one  inch 
and  a  half  in  the  conjugate  diameter.  The  operation  lasted  two  and 
a  half  hours.  At  the  end  of  two  weeks  the  patient  was  able  to  resume 
her  household  duties,  f  Dr.  Osborn,  in  the  celebrated  case  of  Elizabeth 
Sherwood,  extracted  a  child  through  a  pelvis  measuring,  as  he  believed, 
but  three  quarters  of  an  inch  in  its  narrowest  portion  !  Barnes  X  ex- 
tracted with  perfect  success  a  child  through  a  conjugate  Avhich,  he  says, 
certainly  did  not  exceed  one  inch  and  a  half.  It  would  be  easy  to  go 
on  and  extend  this  list,  to  show  that  there  is  no  degree  of  conjugate 
shortening  that  renders  it  utterly  impossible  to  extract  a  mutilated 
child.  But  the  question  which  we  should  ask  for  our  guidance  is,  not 
what  can  possibly  be  accomplished  by  the  skill  and  ingenuity  of  the 
exceptionally  experienced  operator,  who  is  capable  of  making  whatever 
rules  he  likes  to  govern  his  own  actions,  but  what  is  the  point  at  Avhich 
men  in  every-day  practice  need  expect  to  find  the  dangers  from  crani- 
otomy and  the  Csesarean  section  rise  to  nearly  the  same  level.  Dr. 
Parry  collected  seventy  cases  of  craniotomy  in  pelves  measuring  two 
and  a  half  inches  and  nnder.  Seven  had  to  be  terminated,  finally,  by 
Cesarean  section.  Of  the  seventy  women  forty-three  survived  and 
twenty-seven  died.  The  work  was  not  done  by  tyros,  but  by  celebrated 
obstetric  surgeons.  Thus,  the  best  results  of  the  ablest  accoucheurs 
before  the  days  of  antisepsis  showed  a  mortality  from  craniotomy,  in 
the  higher  degrees  of  pelvic  deformity,  of  nearly  forty  per  cent.  Un- 
questionably this  heavy  death-rate  has  been  lowered  by  modern  aseptic 

*  The  limits  are  those  of  Litzmann.  Vide  Ueber  die  Behandlung  der  engcn 
Becken,  Volkraann's  Samml.  klin.  Vortr.,  No.  90. 

f  Michaelis,  Abhandlungen  aus  dem  Gebiete  der  Geburtshiilie,  p.  151.  The 
operation  lasted  two  and  a  half  hours. 

X  Baknes,  Obstetric  Operations,  p.  406. 


TREATMENT  OF   CONTRACTED   PELVES.  495 

methods ;  still,  in  the  hands  of  an  operator  of  limited  experience,  I  be- 
lieve the  Cesarean  section,  when  timely  made,  offers  ordinarily  to  the 
mother  a  better  chance  of  recovery.  There  are,  of  course,  exceptions 
to  the  rule.  Most  pelves  measuring  less  than  two  and  a  half  inches 
in  the  conjugate  belong  to  the  category  of  generally  contracted  flat- 
tened pelves.  Where,  exceptionally,  the  transverse  diameter  is  not  ma- 
terially diminished,  the  difficulties  of  craniotomy  are  greatly  lessened, 
and,  if  at  the  same  time  the  child's  head  be  soft  and  compressible,  a 
comparatively  easy  extraction  may  give  rise  to  false  ideas  concerning 
the  real  dangers  of  delivery  by  the  natural  passages.  These  are  due 
chiefly  to  the  fact  that  the  operation  has  to  be  carried  on  within  the 
uterine  cavity,  when,  owing  to  the  contracted  brim,  no  descent  of  the 
head  is  possible.  A  long  operation  conducted  within  the  uterine  cavity 
is  always  fraught  with  evil. 

The  dangers  are  not  altogether  mechanical.  Even  if  serious  lesions, 
such  as  perforations,  rupture  of  the  uterus,  and  lacerated  wounds,  are 
avoided,  some  contusion  of  the  lower  uterine  segment  is  inevitable,  air 
enters  freely  the  uterine  cavity,  the  patient  exhibits  very  commonly 
the  symptoms  of  profound  shock,  and  the  delivery  is  often  followed  by 
post-partu7n  haemorrhage,  due  to  uterine  inertia.  The  means  employed 
to  check  hemorrhage  tend  still  further  to  depress  the  vital  jDowers.  In 
many  cases  the  uterus  remains  large  and  the  labor  is  followed  by  ca- 
tarrhal endometritis.  This  ordinarily  mild  puerperal  affection  is  apt, 
owing  to  the  introduction  of  air  and  the  presence  of  bits  of  necrosed 
tissue,  to  assume  a  septic  form,  and  pave  the  way  to  a  fatal  termination. 

The  contiguity  of  the  peritonaeum  likewise  adds  to  the  formidable 
character  of  all  suprapelvic  operations.  When  the  outlet  of  the  pel- 
vis alone  is  contracted,  and  craniotomy  can  be  performed  upon  the 
head  after  it  has  entered  the  vaginal  canal,  the  dangers  of  extraction 
are  much  diminished ;  but  even  when  recovery  takes  place,  the  un- 
avoidable injuries  inflicted  often  lead  to  life-long  invalidism. 

Cases  of  extreme  degrees  of  the  justo-minor  pelvis  are  believed  to  be  excess- 
ively rare.  Certainly  tlie  whole  number  reported  since  Naegele's  day  may  be 
easily  counted  on  the  fingers  of  the  two  hands.  At  full  term  the  labor  takes 
place,  provided  the  general  contraction  is  such  as  to  retain  the  head  at  the  brim, 
in  one  of  two  ways : 

1.  The  uterus  retracts  up  over  the  head  of  the  child.  If  the  head  does  not 
descend,  the  vagina  is  drawn  upward  and  is  exposed  to  injurious  tension.  Should 
nothing  be  done  to  relieve  this  condition,  the  thin  vagina  is  liable  to  be  rubbed 
through  by  the  pressure  it  encounters  at  the  brim,  and  especially  at  the  symphy- 
sis pubis.  Version  would  here  be  impossible,  and  the  forceps  would  only  en- 
hance the  risks.  Perforation  and  decerebration  would  at  once  diminish  the 
pressure.  With  little  over  three  inches  in  the  conjugate  and  four  in  the  trans- 
verse diameter,  the  vault  of  the  skull  may  be  broken  up  with  the  cranioclast, 
the  chin  tilted  downward,  and  the  head  brought  edgewise  through  the  pelvis. 
In  this  way,  with  moderate  skill,  it  would  be  possible  to  extract  a  dead  child. 


496  THE  PATHOLOGY  OF  LABOR. 

The  operation  of  laparo-elytrotomy,  however,  seems  so  peculiarly  fitted  to  these 
conditions,  that  it  deserves  a  trial  in  the  interest  of  both  mother  and  child. 

2.  The  membranes  rupture  early,  the  waters  gradually  escape,  and,  as  the 
head  does  not  descend,  the  uterus  retracts  down  firmly  upon  the  child.  A  scalp- 
tumor  forms,  which  fixes  the  head  at  the  brim  and  pushes  the  cervix  and  lower 
segment  of  the  uterus  before  it.  Here  it  would  be  proper  to  await  for  a  time 
the  results  of  uterine  action.  As  the  transverse  diameter  can  only  be  roughly 
estimated,  the  head  may  lengthen  out  and  adapt  itself  to  the  pelvic  canal.  But 
the  delay  should  not  be  too  prolonged.  If,  in  spite  of  the  formation  of  the 
scalp-tumor,  the  bony  head  remains  unmoved  at  the  brim,  it  is  a  question 
whether  it  would  not  be  the  wiser  plan  to  proceed  at  once  to  the  Caesarean 
section. 

Naegele  *  reports  the  history  of  a  dwarf  whose  pelvis  measured  but  three 
inches  and  seven  lines  in  the  transverse  and  three  inches  in  the  conjugate.  He 
delivered  her  with  forceps  of  a  five-and-a-half -pound  child,  but  she  died  on  the 
tenth  day.  Heim  reports  the  history  of  a  dwarf  with  three  and  a  quarter  inches 
conjugate  and  four  and  three  quarters  inches  transverse  diameter.  Delivery 
by  perforation  and  forceps.     Rupture  of  the  three  articulations.t 

Spiegelberg  reports  a  case  with  nearly  the  same  dimensions.  Child  pre- 
sented by  the  breech.  Extraction  difficult.  Perforation  of  after-coming  head. 
Cephalotripsy.  The  patient  died  shortly  after  delivery.  J  I  have  reported  a 
case  .where  the  conjugate  was  three  and  one  sixth  inches  and  the  transverse 
four  and  a  half  inches.  Delivery  by  perforation,  the  cranioclast,  and  the 
crotchet.  The  patient  died  on  the  third  day  (Trans,  of  the  Am.  Gynaec.  Soc, 
vol.  iv).  Kormann  relates  a  ca.se  nearly  identical  with  my  own,  both  as  regards 
its  diameters  and  the  existence  of  a  slight  lateral  obliquity.  After  over  three 
days'  labor  the  head  adapted  itself  to  the  pelvis,  and  the  child  was  extracted 
alive  by  forceps.     The  mother  died  of  peritonitis.* 

Thus,  of  five  women  with  generally  contracted  pelves,  in  which  the  conju- 
gate ranged  from  three  to  three  and  a  quarter  inches,  all  died  as  a  consequence 
of  delivery  through  the  natural  passages. 

In  cases  where  the  uterus  is  rigidly  applied  to  the  child,  and  the  cervix  is 
undilated,  the  propriety  of  laparo-elytrotomy  is  questionable.  The  operation 
is  not  always  a  very  easy  one,  and  it  certainly  can  not  afford  to  be  handicapped 
by  anything  which  would  cause  delay  in  the  delivery  after  the  vaginal  rent  has 
been  made. 

There  are,  of  course,  in  so  rare  a  condition,  scant  statistics  in  favor  of  any 
special  plan  of  treatment.  Michaelis  reports  a  case  of  Mantz's,  that  of  a  woman 
who  had  a  pelvis  measuring  two  inches  antero-posteriorly  and  three  inches  in 
the  transverse  diameter.  Here  the  Caesarean  section  became  a  matter  of  neces- 
sity rather  than  one  of  election.  Twice  the  operation  was  performed  with  suc- 
cess. A  third  time  the  result  promised  to  be  equally  favorable,  but  the  willful 
and  insubordinate  conduct  of  the  patient,  as  late  as  the  twenty-seventh  day,  led 
to  her  destruction. 

In  spite  of  the  fact  that  in  generally  contracted  pelves  craniotomy  is  nearly 

*  Naegele,  Das  sehrag  verengte  Becken,  p.  102. 
•f  LOHLEIN,  op  cit.,  p.  42. 

X  Spiegelberg,  Lehrbuch  der  Geburtshiilfe,  p.  444,  vide  note. 

*  KoRMAXN,  Ueber  ein  allgemein  verengtes,  schrag  verschobenes  Becken,  Arch 
f  Gynaek.,  p.  472. 


TREATiJENT   OF  CONTRACTED   PELVES.  497 

always  practicable,  a  careful  study  of  the  ground  convinces  me  that  where 
there  is  a  diminution  of  nearly  an  inch  in  all  the  diameters,  Csesarean  section 
holds  out  the  best  chance  for  saving  the  mother's  life. 

2.  Cases  hi  wliicli  tlie  pdvic  contraction  is  such  as  to  prevent  the 
hirth  of  a  full-term  living  child  through  the  natural  ^jcissages,  but 
in  luhich  extraction  through  the  jJ&lvis  furnishes  the  best  chance  of 
saving  the  life  of  the  mother.  The  choice  of  measures  in  this  class  of 
cases  lies  between  the  Caesarean  section,  craniotomy,  and,  where  the  con- 
dition of  things  is  recognized  early  enough,  the  induction  of  premature 
labor.  In  general  terms  we  are  authorized  to  assume  such  a  degree  of 
disproportion  in  flattened  pelves  with  the  conjugate  ranging  between 
two  and  a  half  and  three  inches,  and  in  justo-minor  pelves  with  a  con- 
jugate measuring  three  and  a  third  inches.  In,  however,  these  less  ex- 
treme degrees  of  deformity,  other  elements  than  those  of  the  size  of  the 
pelvic  canal  enter  into  the  formation  of  an  opinion  regarding  the  proper 
procedure  to  be  selected.  I  have,  myself,  in  one  case,  extracted  a  child 
weighing  six  and  a  half  pounds  by  forceps,  without  much  difficulty, 
through  a  generally  contracted  flattened  pelvis  with  a  conjugate  meas- 
uring barely  two  and  three  fourths  inches.  Labor  had  lasted  three 
days  previous  to  my  seeing  the  patient,  which  was  in  consultation. 
The  child's  head  presented  a  singular  appearance,  from  the  molding  it 
had  undergone,  having  been  greatly  flattened  in  its  biparietal  diameter 
and  enormously  elongated  in  the  occipito-mental  direction.  The  child 
died,  however,  shortly  after  birth.  The  mother  recovered,  though  con- 
siderable sloughing  of  the  vaginal  walls  followed  the  long  continuance 
of  the  pressure  which  had  preceded  delivery.  Grenser,  in  the  Dresden 
Hospital  Eeports  (1861-'63),  gives  three  cases  of  children  born  alive 
where  the  pelvis  measured  two  and  three  quarters  inches.  In  one  of 
these,  where  the  labor  lasted  twenty-two  hours,  a  living  child  was  born 
weighing  six  and  a  half  pounds. 

If,  therefore,  labor  comes  on  at  full  term,  an  attempt  should  first 
be  made  to  gauge  the  degree  of  disproportion  between  the  head  and 
the  pelvic  brim,  for  not  only  is  it  among  the  bare  possibilities  that  a 
living  child  may  be  expelled  through  a  j^elvis  measuring  less  than 
three  inches,  but  it  is  to  be  borne  in  mind  that  in  pelvic  mensuration 
even  the  most  expert  may  make  errors  of  a  quarter  of  an  inch.  In 
any  case  it  is  well  to  preserve  the  membranes  as  long  as  possible. 
Even  craniotomy  is  more  easily  performed  after  complete  dilatation  of 
the  OS.  After  the  waters  escape,  the  lower  uterine  segment  is  subjected 
to  injurious  pressure  between  the  hard  skull  and  the  pelvic  rim,  the 
damage  done  increasing  of  course  with  the  duration  of  labor.  By 
early  perforation  and  evacuation  of  the  brain-mass  this  danger  is 
avoided.  But  craniotomy  should  not  be  performed  so  long  as  the  hope 
exists  of  saving  the  life  of  the  child.  The  attempt  should  be  made,  at 
least.,  before  perforating,  to  form  an  estimate  of  the  size  of  the  child's 
32 


V 


498  THE  PATHOLOGY  OP  LABOK. 

head  and  its  relations  to  the  pelvic  brim.  An  approximative  result 
may  be  obtained  by  palpating  the  head  through  the  abdominal  walls 
above  the  pubes,  and,  so  soon  as  the  cervix  is  dilated  and  the  head  be- 
comes pressed  by  the  labor-pains  firmly  against  the  brim,  by  introduc- 
ing the  half -hand  into  the  vagina  to  determine  the  extent  of  that  por- 
tion of  the  cranial  vault  which  has  entered  the  pelvis.  When  we  have 
ascertained  the  size  of  the  segment  beneath  the  pelvic  border,  and  the 
special  points  of  the  head  which  occupy  the  several  pelvic  diameters, 
we  are  in  a  position  to  estimate  the  size  of  the  portion  above  the  brim, 
and  the  mechanical  difficulties  which  remain  before  the  engagement  of 
the  head  can  be  accomplished. 

In  shoulder  presentations,  where,  of  course,  version  is  necessary, 
extraction  alone  should  be  first  tried,  and  only  when  it  is  found  impos- 
sible to  effect  the  delivery  of  the  after-coming  head  by  other  means 
should  perforation  be  resorted  to.  Schroeder  claims  to  have  extracted 
living  children  through  pelves  measuring  but  seven  and  a  half  centi- 
metres (three  inches)  in  the  conjugate.* 

The  induction  of  premature  labor  in  pelves  having  from  two  and 
three  quarters  to  three  inches  conjugate  diameter  possesses  the  merit 
of  diminished  risk  to  the  mother,  and  affords  a  chance  of  saving  the  life 
of  the  child.  Below  two  and  three  quarters  inches  the  advantages  of 
premature  labor  may  be  fairly  called  in  question.  To  be  sure,  Kiwisch 
placed  the  biparietal  diameter  of  the  child's  head  in  the  thirtieth 
week  at  two  and  a  half  inches.  Seyfert,  however,  fixed  it  at  three 
inches,  and  later  Schroeder  obtained  nearly  three  and  a  quarter  inches 
(8*16  centimetres)  as  the  average  between  the  twenty-eighth  and  thirty- 
second  week.  In  point  of  fact  there  is  too  little  uniformity  in  the 
diameters  of  fetal  heads  belonging  presumably  to  the  same  week  of 
development  to  make  average  measurements  of  any  practical  utility. 
It  will  be  seen,  however,  that,  in  the  higher  degrees  of  pelvic  contrac- 
tion we  are  now  contemplating,  the  biparietal  diameter  of  the  child's 
head  rarely  falls  within  the  limits  of  the  narrowed  conjugate.  Still, 
it  is  possible  to  deliver  a  living  child  through  a  pelvis  estimated  at  two 
and  three  quarters  inches  as  late  as  the  thirty-fourth  week,f  as  the 
head,  owing  to  the  pliability  of  the  cranial  bones  in  premature  chil- 
dren, is  capable  of  sustaining  a  considerable  degree  of  lateral  comjires- 
sion.  Naturally  the  infant  mortality  in  these  cases  is  very  large.  In 
addition  to  the  ordinary  increased  risks  attendant  upon  premature 
labor,  intracranial  extravasations  of  blood  from  rupture  of  the  deli- 
cate cerebral  vessels  are  extremely  common.  Litzmann  found  in 
nearly  one  fourth  of  his  cases  (8  :  34)  spoon-shaped  dejiressions  of  the 
skull.     Though  this  lesion  is  met  with  upon  the  heads  of  living  chil- 

*  Schroeder,  Lehrbuch  der  Geburtshiilfe,  p.  539. 

f  Wiener,  Zur  Frage  der  ktinstlichen  Friihgeburt,  Arch.  f.  Gynaek,  Bd.  xiii, 
p.  99. 


TREATMENT   OF  CONTRACTED   PELVES.  490 

dren  at  full  term,  in  the  series  of  Litzmann  four  of  the  children  were 
dead  at  birth,  three  showed  feeble  signs  of  vitality,  and  in- one  .only, 
which  lived  but  fourteen  hours,  was  it  possible  to  excite  the  respira- 
tory process.  Thus,  the  outlook  for  the  child  is  by  no  means  hopeful ; 
but,  inasmuch  as,  under  three  inches,  the  only  operations  which  come 
into  competition  with  premtiture  labor  are  the  Cesarean  section  and 
craniotomy,  a  small  saving  of  fetal  life  is  a  powerful  plea  in  its  Justifi- 
cation. But  a  stronger  argument  in  its  favor  is  the  fact  that  the  in- 
duction of  premature  labor  offers  a  milder  procedure,  which,  within 
certain  limits,  inures  to  the  benefit  of  the  mother. 

Below  two  and  three  fourths  inches  the  chances  of  saving  the  child 
by  premature  labor  are  too  slight  to  be  weighed  in  the  balance.* 
Moreover,  unless  the  child's  head  happens  to  be  exceptionally  small 
and  yielding,  approximating  the  conditions  to  those  which  obtain  in 
immature  deliveries,  craniotomy  in  the  end  has  usually  to  be  resorted 
to.  Now,  as  premature  labor  offers  no  peculiar  advantages  in  the  per- 
formance of  craniotomy,  and,  as  it  is  attended  with  certain  risks  of  its 
own,  it  is  advisable,  in  very  narrow  pelves  after  the  twenty-eighth 
week,  to  await  the  normal  end  of  gestation. 

As  the  dangers  to  both  mother  and  child  are  increased  by  delay, 
Barnes  has  proposed  combining  version  with  premature  labor  in  pelves 
of  less  than  three  inches  conjugate,  as  a  means  of  accelerating  delivery. 
Milne  by  this  method  extracted  a  living  child  through  a  two  and  a 
half  inch  pelvis.  Budin  has  found  by  experimentation  with  artificial 
2:)elves  that  a  much  less  amount  of  traction  force  is  requisite  to  drag 
the  head  of  a  premature  child  through  a  flattened  conjugate  by  the 
feet  than  by  forceps  in  cephalic  presentations. 

The  time  is  probably  not  far  distant  when  it  will  be  possible  to  substitute 
the  Caesarean  section  for  craniotomy  within  the  limits  of  pelvic  contraction 
vmder  consideration.  Craniotomy  requires  rigid  antisepsis,  a  sufficient  arma- 
mentarium, and  an  accurate  knowledge  of  the  parturient  passage.  With  the 
adoption  of  modern  methods  in  hospital  practice,  Olshausen  reports  a  death- 
rate  from  craniotomy  of  5-7  per  cent;  Cfed6,  a  death-rate  of  8  per  cent;  and 
Gusserow  reports  from  Berlin  a  death-rate  of  14-3  per  cent,  or,  excluding  cases 
in  which  the  death  had  nothing  to  do  with  the  operation,  the  death  percentage 
was  reduced  to  8-3  per  cent.  Leopold  had  71  cases  with  two  deaths;  but  the 
latter  were  from  eclampsia,  and  were  not  the  result  of  the  operation.! 

For  the  successful  performance  of  the  Caesaiean  section  there  is  needed  train- 
ing, adequate  preparation,  skilled  assistants,  and  that  the  resistance  of  the  patient 

*  In  support  of  this  opinion,  which  is  thoroughly  confirmed  by  my  own  experi- 
ence, we  have  especially  the  authority  of  Spiegelberg,  Litzmann,  and  Dohrn. 
Milne  (Premature  Labor  and  Version,  Edinburgh  Med.  Jour.,  vol.  xix.  p.  707)  re- 
lates a  case  where  he  was  successful  in  a  pelvis  measuring  but  two  and  a  half  inches. 
He  states,  however,  that  the  space  in  the  other  diameters  of  the  brim  was  ample, 
which  was  certainly  an  exceptional  advantage,  as  nearly  all  pelves  with  the  higher 
grades  of  deformity  belong  to  the  category  of  generally  contracted  rachitic  pelves. 

f  Praegek,  Der  Kaiserschnitt,  etc.,  herausgegeben  von  Dr.  G   Leopold. 


500 


THE  PATHOLOGY  OF  LABOR. 


shall  not  be  too  much  weakened  by  protracted  delay.  Of  252  cases  operated 
on  according  to  the  method  of  Sanger,  between  the  years  1882-'89,  inclusive, 
63  (25  per  cent)  terminated  fatally,  but  in  1890,  of  61  cases,  only  7  women 
died  (11-4  percent).  The  possibilities  of  the  improved  Csesarean  section  is, 
however,  best  shown  in  the  results  obtained  by  single  favored  operators.  Thus 
Leopold  had  had  up  to  August,  1890,  42  cases  with  four  deaths,  and  in  Leipsic, 
of  36  cases,  only  2  terminated  fatally.  Murdoch  Cameron  had  9  cases  (simul- 
taneous removal  of  the  ovaries)  with  the  loss  of  1  patient.  Sanger  had  8 
cases,  Van  der  Meig  7  cases,  and  Schauta  15  cases  without  a  death.* 

3.  Cases  in  loMch  the  pelvic  contraction  does  not  exceed  the  limits 
within  which  the  deliver ij  of  a  living  child  at  term  is  at  least  possible. 
In  this  category  belong  the  overwhelming  majority  of  all  instances 
of  contracted  pelvis.  It  embraces  not  only  cases  in  which  the  con- 
junction of  every  favorable  condition  is  essential  to  delivery,  but  those 
moderate  degrees  of  narrowing  which  are  chiefly  recognizable  through 
the  influence  they  exert  upon  the  mechanism  of  labor.  It  includes 
flattened  pelves  with  a  conjugate  of  three  inches  and  upward,  and" 
justo-minor  pelves  with  a  conjugate  of  over  three  and  a  third  inches. 
Below  these  figures  the  delivery  of  living  children  at  full  term  is  too 
exceptional  an  event  to  be  taken  into  account  in  any  attempt  at  classi- 
fication. 

The  obstetrical  resources  for  overcoming  the  mechanical  obstacles 
afforded  by  moderate  degrees  of  pelvic  contraction  are  the  induction 
of  premature  labor,  craniotomy,  forceps,  and  version.  Each  one  of 
these  measures  has  its  strenuous  partisans,  who  have  expended  much 
unprofitable  zeal  in  comparative  estimates  of  their  respective  values. 
It  is  a  mistake  to  regard  them  as  rival  pretenders  to  favor.  Indeed, 
the  very  conditions  which  indicate  one  form  of  procedure  often  ex- 
'clude  the  others  from  consideration.  Good  midwifery  requires  a  just 
appreciation  of  all  the  auxiliaries  at  our  disposition  and  a  careful  study 
of  the  circumstances  which  render  them  severally  appropriate. 

Premature  Labor. — The  indiscriminate  induction  of  premature 
labor  in  every  case  of  contracted  pelvis  is  particularly  to  be  deprecated. 
In  the  first  volume  of  the  Archiv  fiir  Gynaekologie  Spiegelberg  pre- 
sented the  statistics  of  1,224  cases  of  full-term  labor  in  contracted 
pelvis,  in  which  the  maternal  mortality  was  Q-Q  per  cent  and  the  in- 
fant mortality  28  per  cent ;  while  in  271  cases  of  induced  premature 
labor  the  maternal  mortality  was  18*8  per  cent  and  the  infant  mor- 
tality 66  per  cent.  This  startling  discrepancy  is  due  to  the  fact  that 
a  very  large  proportion  of  labors  in  contracted  pelves  either  terminate 
spontaneously  or  require  forceps  only  after  uterine  action  has  over- 
come the  obstruction  at  the  brim.  If  all  these  minor  cases  be  omitted, 
a  very  different  result  is  obtained.     Thus,  Litzmann  found  that  in  flat- 

*  Jahresbencht  ueber  die  Fortschritte  auf  dem  Gebiete  der  Gcburtshlilfe  und 
Gynaek.,  Ill  Jahrgang,  s.  294,  und  IV  Jahrgang,  s.  816. 


TllEATMEXT   OF  CONTRACTED   PELVES.  501 

tened  pelves  measuring  from  two  and  three  fourths  to  three  and  one 
fourth  inches  in  the  conjugate,  and  in  justo-miuor  pelves  between 
three  and  one  third  and  three  and  a  half  inches,  the  maternal  mortal- 
ity after  premature  labor  amounted  to  7'4  per  cent,  while  the  loss  of 
life  in  labors  at  full  term  was  18-7  per  cent.*  But,  in  cases  of  recov- 
ery, the  advantages  of  premature  delivery  are  by  no  means  inconsider- 
able, as,  owing  to  the  diminished  head-pressure,  lesions  of  the  genital 
canal  are  of  rare  occurrence,  in  striking  contrast  to  the  fistulfe,  lacera- 
tions, and  cicatrices  which  so  often  follow  delivery  at  full  term. 

The  prognosis  for  the  child,  as  shown  by  the  statistics  of  premature 
labor  in  contracted  pelves,  is  decidedly  unfavorable.  In  the  restricted 
class  of  cases  we  are  at  present  considering  Litzmann  found  that, 
though  twice  as  many  children  were  born  alive  as  at  full  term,  the 
actual  number  discharged  alive  from  the  hospital  was  about  the  same. 
He  concluded,  therefore,  that,  Avhile  the  operation  was  decidedly  indi- 
cated in  the  interests  of  the  mother,  it  offered  a  dubious  advantage  to 
the  child.  It  is,  however,  always  injudicious  to  draw  deductions  from 
hospital  statistics  alone.  Especially  is  this  true  of  feeble  children, 
born  prematurely,  whose  ultimate  chances  depend  in  a  peculiar  degree 
upon  the  care  with  which  they  are  tended. 

Dohrn,  who  objected  to  the  statistics  of  Spiegelberg  and  Litzmann, 
on  the  ground  that  the  units  of  which  they  were  composed  repre- 
sented, not  parallel  cases,  but  an  endless  variety  of  dissimilar  condi- 
tions, proposed,  as  a  fairer  way  of  testing  the  value  of  induced  prema- 
ture labor,  to  compare  the  results  of  the  latter  operation  with  those 
of  full-term  labors  in  the  same  patients.  Viewed  in  this  way,  prema- 
ture labor  in  contracted  pelves  has  been  found  to  furnish  unexpectedly 
favorable  results.  Thus,  Dohrn  reports  nineteen  cases,  with  forty-one 
children  at  term,  of  which  thirty-seven  died.  In  twenty-five  preg- 
nancies premature  labor  was  induced,  with  fifteen  living  children,  f 
Kiinne  and  Berthold  report  eight  cases,  with  twenty-four  children  at 
term,  of  which  eighteen  died.  In  eighteen  pregnancies  premature 
labor  was  induced,  with  thirteen  living  children. J  Still  more  extraor- 
dinary is  the  report  of  Milne.  Six  women  gave  birth  at  term  to  twelve 
children,  of  which  eleven  were  dead.  In  the  succeeding  thirty-eight 
pregnancies  premature  labor  was  induced,  and  thirty-five  children  were 
born  living.* 

The  ordinary  time  for  bringing  on  labor  is  from  the  thirty-second 
to  the  thirty-fourth  week.     Most  writers  now  agree  that  the  oi^eration 

*  Litzmann,  Ueber  den  Werth  der  kiinstlich  eingleiteten  Friihgeburt  bei  Beck- 
enenge.  Arch.  f.  Gynaek.,  Bd.  ii.  p.  194. 

f  Dohrn.  Ueber  kiinstliche  Friihgeburt  bei  engen  Becken,  Arch.  f.  Gvnaek.,  Bd. 
xii,  p.  70. 

I  Kt'NNE,  Fiinfzchn  Fiille  der  kiinstlichen  Friihgeburt;  Berthold,  Zur  Statistik 
der  kiinstlichen  Friihgeburt,  Arch.  f.  Gynaek.,  Bd.  vi,  Ileft  2. 

*  Milne,  Premature  Labor  and  Version,  Edinburgli  Med.  Jour.,  vol.  xix. 


502  THE  PATHOLOGY  OP  LABOR. 

should  be  restricted  to  pelves  measuring  less  than  three  and  a  half 
inches  in  the  conjugate,  whereas  above  that  limit  it  is  best  to  await 
the  results  of  spontaneous  uterine  action. 

Labor  at  End  of  Gestation.— But  the  physician  may  first  be  sum- 
moned to  a  case  of  contracted  pelvis  after  the  end  of  gestation  has 
been  reached,  or  he  may  at  an  earlier  period  have  decided  against  the 
induction  of  premature  labor. 

At  full  term,  supposing  the  head  to  present,  the  latter,  at  the  be- 
ginning of  labor,  is  prevented  by  the  pelvic  narrowing  from  entering 
the  brim  of  the  pelvis,  and  is  usually  freely  movable.  The  conduct  of 
the  first  stage  of  labor  should  be  directed  to  preparing  the  way  for  the 
subsequent  delivery  of  the  child.  To  this  end  every  pains  should  be 
taken  to  prevent  rupture  of  the  membranes  until  the  cervical  dilata- 
tion has  become  complete.  The  patient  should  be  cautioned  against 
restless  movements  in  bed,  and  from  bearing  down  during  the  pains. 
Examinations  joer  vaginam  should  be  made  with  great  care,  and  should 
be  avoided  except  where  absolutely  necessary.  The  largest-sized  Barnes 
dilator,  moderately  distended  with  fluid,  placed  in  the  vagina  to  exert 
counter-pressure  upon  the  cervix,  is  at  times  of  use  where  the  mem- 
branes have  a  tendency  to  protiiide  in  the  form  of  a  narrow  cylinder. 

Attention  should  likewise  be  directed  to  faulty  positions  and  pres- 
entations of  the  child's  head.  Should  these  be  dependent  upon  a 
pendulous  abdomen,  the  fundus  of  the  uterus  should  be  elevated,  and 
the  normal  relations  of  the  uterine  axis  maintained  by  a  suitably  ad- 
justed bandage.  Excessive  lateral  obliquity  should  be  corrected  by 
placing  the  patient  upon  the  opposite  side.  Should  transverse  nar- 
rowing require  a  deep  descent  of  the  occiput,  this  can  be  furthered  by 
placing  the  woman  upon  the  side  to  which  the  occiput  is  directed. 
Where,  on  the  other  hand,  it  is  desirable  to  promote  the  dip  of  the 
forehead,  the  patient  should  be  made  to  lie  upon  the  side  to  which  the 
child's  face  is  turned.  The  reason  of  this  is  obvious,  as,  when  the 
breech  falls  to  a  given  side,  the  ceplialic  pole  has  a  tendency  to  move 
in  the  opposite  direction.  The  right  use  of  position  as  a  corrective 
force  depends  upon  the  degree  of  accuracy  with  which  the  character 
of  the  pelvic  deformity  is  estimated,  and  upon  a  proper  appreciation 
of  the  mechanism  appropriate  to  the  ascertained  deformity. 

Where  the  sagittal  suture  looks  forward  toward  the  symphysis 
pubis,  so  that  the  posterior  parietal  bone  becomes  the  presenting  part, 
a  firm  compress  above  the  pubes  may  be  advantageously  employed  to 
press  the  head  backward  and  approximate  the  sagittal  suture  to  the 
median  line. 

The  paint',,  when  weak  and  inefficient,  should  be  strengthened  by 
the  warm  vaginal  douche ;  when  the  source  of  exaggerated  suffering, 
they  should  be  mitigated  by  morphine,  by  rectal  injections  of  chloral, 
or  by  the  administration  of  an  anaesthetic. 


TREATMENT   OF  CONTRACTED   PELVES.  503 

Should,  by  good  fortune,  the  rupture  of  the  membranes  bo  post- 
poned until  after  the  completion  of  cervical  dilatation,  one  of  two 
contingencies  may  follow :  1.  The  disproportion  between  the  head  and 
the  pelvis  may  prove  to  be  slight,  so  that  a  considerable  segment  of  the 
cranial  vault  may  be  felt  below  the  brim ;  then,  provided  the  head  en- 
ters the  pelvis  in  conformity  with  the  mechanical  laws  dictated  by  the 
character  of  the  pelvic  deformity,  the  expulsion  of  the  child  may  be  left 
to  the  natural  uterine  forces.  2.  No  engagement  may  take  jjlace,  the 
head  continuing  freely  movable  at  the  brim.  Under  such  circum- 
stances the  disjiroportion  may  be  assumed  to  be  considerable.  The 
physician  has,  therefore,  to  ask  himself  whether  he  shall  await  the 
action  of  the  pains,  in  the  expectation  that  the  head  will  gradually 
adapt  itself  to  the  pelvis,  or  whether  he  shall  at  once  jjroceed  to  per- 
form version,  and  drag  the  child  rapidly  through  the  straitened  diam- 
eters. The  forceps,  as  a  means  of  delivery  before  fixation  of  the  head, 
should  be  discarded,  not  because  it  can  not  be  employed  with  sliccess, 
but  because  its  use,  even  in  the  most  skillful  hands,  is  extra-haz- 
ardous. 

The  question  of  waiting,  or  proceeding  at  once  to  version,  is  one 
that  will  always  be  decided  largely  by  the  individual  experiences  of  the 
accoucheur.  It  is,  however,  vain  to  deduce  rules  of  practice  from  the 
conduct  of  those  who  have  enjoyed  exceptional  opportunities,  and  who 
usually  have  developed  exceptional  skill  in  some  one  special  direc- 
tion. It  is  to  be  remembered  that  in  contracted  pelves,  in  case  the 
pains  prove  inadequate  to  overcome  the  obstacles  to  delivery,  the  alter- 
natives in  head  presentations  are  forceps  and  perforation.  But  there 
are  very  few  experienced  operators  who  have  not  a  more  or  less  per- 
sonal predilection  for  either  forceps  or  version,  and  this  unconscious 
bias  exercises,  necessarily,  to  some  extent,  a  determining  influence  upon 
their  choice.  It  is  well  known  that  there  is  hardly  any  subject  which 
has  been  the  source  of  so  much  heated  controversy  as  the  one  at  pres- 
ent under  discussion.  For  the  profession  at  large,  however,  there  is 
little  to  be  gained  from  the  spirit  of  partisanship.  The  general  prac- 
titioner requires  instruction  not  only  in  the  special  advantages  pos- 
sessed by  each  measure,  but  need,3  to  have  presented  to  his  attention 
parallel  statements  of  the  dangers  and  difficulties  from  which  neither 
procedure  is  free. 

Version. — In  considering  the  application  of  version  to  the  treat- 
ment of  contracted  pelves,  it  is  well  to  state  in  advance  certain  points 
which  are  rarely  alluded  to,  probably  because  they  are  matters  of  tacit 
agreement  between  the  contending  parties  to  whose  disputes  we  main- 
ly owe  our  present  knowledge  in  relation  to  the  subject. 

The  first  of  these  points  is,  that  the  intent  of  the  operation  is  to 
save  tlie  life  of  the  child.  In  the  case,  therefore,  of  a  dead  child,  or  of 
one  in  which  the  heart-sounds  have  notably  begun   to  fail,  version 


504 


THE  PATHOLOGY  OF  LABOR. 


affords  no  advantage  over  perforation.  For  the  same  reason  the  condi- 
tions must  be  such  as  to  hold  out  a  reasonable  hope  of  rapid  delivery 
of  the  child's  head,  without  the  infliction  of  necessarily  fatal  lesions. 
Now,  there  does  not  appear  to  be  any  well-authenticated  case  of  the 
extraction  of  a  full-term  living  child  after  version  through  a  flattened 
pelvis  measuring  less  than  two  and  three  quarters  inches  in  the  conju- 
gate diameter.  But  even  with  three,  or  three  and  a  quarter  inches, 
the  result  will  still  depend  upon  the  length  of  the  transverse  diameter. 
Thus,  in  extreme  degrees  of  the  justo-minor  pelvis,  with  the  reduction 
of  nearly  an  inch  in  all  the  diameters,  the  difficulties  of  delivering  the 
after-coining  head,  even  with  the  aid  of  the  perforator  and  the  cephalo- 
tribe,  are  well-nigh  insurmountable.  Again,  the  contraction  should 
be  limited  to  the  pelvic  brim,  for,  where  it  is  continuous,  or  progres- 
sively increases  toward  the  outlet,  the  fate  of  the  child  is  not  even 
doubtful. 

The  other  point  of  importance  is,  that  with  three  and  a  half  inches 
and  upward  in  the  conjugate,  no  interference  is,  as  a  rule,  called  for. 
Since  it  has  become  the  custom  to  measure  pelves  with  accuracy,  the 
profession  has  learned  that  these  moderate  degrees  of  deformity  exer- 
cise their  influence  not  so  much  in  a  mechanical  way  as  in  the  modi- 
fying effects  they  produce  upon  labor.  A  large  proportion  of  the  cases 
terminate  spontaneously.  If  the  pains  fail  prematurely,  the  conditions 
are  generally  such  as  to  make  it  an  easy  matter  to  deliver  with  forceps. 
Difficulties  only  arise  where  the  head  is  unusually  large  and  incom- 
pressible, or  in  faulty  positions,  such  as  the 
anterior  dip  of  the  head  in  justo-minor 
pelves,  and  the  presentation  of  the  posterior 
parietal  bone  in  the  flattened  varieties. 

Thus,  version  is  indicated  in  contracted 
j)elves  only  where  the  child's  heart  beats 
with  nearly  unimpaired  vigor  and  in  pelves 
measuring  between  two  and  three  quarters 
and  three  and  a  half  inches  antero-pos- 
teriorly,  with  the  contraction  limited  to  the 
brim,  and  with  sufficient  amplitude  in  the 
transverse  diameter. 

The  advantages  of  version  in  contracted 
pelves  grow  out  of  the  unquestioned  fact  that 
the  after-coming  head  passes  more  readily  the 
contracted  brim  than  the  normal  head-first 
presentation.  This  superior  facility  is  attributable  to  the  entry  of  the 
head  by  its  smaller  bimastoid  diameter.  At  the  same  time,  the  fronto- 
occipital  descends  in  the  transverse  diameter  of  the  pelvis.  The  press- 
ure of  the  conjugate  is  encountered  by  the  bitemporal  diameter  of 
the  child's  head,  which  measures  a  half-inch  less  than  the  biparietaL 


Fig.  211.— Base  of  skull.    M  M, 
bimastoid  diameter. 


TEEATMENT  OF  CONTRACTED  PELVES. 


505 


Tractions  upon  the  trunk  of  the  child  bring  to  bear  simultaneously 
pressure  upon  the  head  from  many  points  in  the  pelvic  walls.  As  a 
result,  bilateral  flattening  is  effected,  and  a  deep  groove,  usually  near  the 
coronal  suture,  is  produced  in  many  cases  upon  the  posterior  cranial 
surface  by  the  pressure  of  the  projecting  promontory.  The  bulk  of  the 
head  is  still  further  diminished  by  an  overriding  of  the  bones  at  the 
sagittal  suture,  and,  where  the  transverse  diameter  is  insufficient,  by 
the  crowding  of  the  occipital  beneath  the  parietal  bones.  A  reduction 
of  the  cranial  contents  is  brought  about  by  the  retreat  of  a  consider- 
able portion  of  the  cerebro-spinal  fluid  into  the  spinal  canal.  All  these 
changes  are  induced  rapidly,  and  are  not  dependent  upon  the  activity 
and  strength  of  the  uterine  pains. 

The  method  of  performing  version  and   extraction  in  contracted 
pelves  io,  with  few  modifications,  the  same  as  in  pelves  of  normal  size. 


Fig.  212.— Method  of  employing  suprapubic  pressure.    Head  in  the  pelvic  cavity.    (Mund6.) 

In  contracted  pelves  great  care  requires  to  be  taken  lest  the  arms  be- 
come reflected  upward  to  the  sides  of  the  child's  head,  or  crossed  upon 
the  neck.  To  avoid  this  difficulty  it  is  desirable  to  introduce  the 
hand  over  the  abdomen  of  the  child,  and  bring  down  the  arms  before 
the  engagement  of  the  shoulders.  In  extracting  the  head,  tractions 
may  be  made  upon  the  lower  extremities  and  shoulders  according  to 
the  method  of  Kiwisch,  or  they  may  be  made  with  one  hand  upon 
the  shoulders,  while  two  fingers  of  the  other  are  inserted  into  the 
child's  mouth.  Provided  by  either  of  these  methods  the  relation  of 
the  head  to  the  shoulders  is  such  that  no  twisting  of  the  neck  takes 
place,  the  amount  of  force  that  can  be  employed  without  producing 


506  THE  PATHOLOGY  OF  LABOR. 

fat^l  lesions  is  often  something  astounding.  Thus,  Eokitansky,*  ex- 
perimenting with  the  bodies  of  still-born  infants,  found  the  utmost 
ctrength  put  forth  by  two  men  upon  the  trunk  was  insufficient  to 
cause  rupture  of  the  vertebral  ligaments  and  separation  of  the  artic- 
ulations. It  is  usual,  however,  to  combine  pressure  from  above, 
exercised  by  a  skilled  assistant  upon  the  head  through  the  abdominal 
walls,  with  tractions  from  below.  Schroeder  states  f  that  this  practice 
is  coeval  with  podalic  version.  It  was  known  to  Cclsus  and  recom- 
mended by  Ambroise  •  Pare.  It  has  found  warm  advocates  in  Pugh, 
Wigand,  Martin,  Kristeller,  and  in  this  country  in  Taylor  and  Goodell. 
Both  the  latter  gentlemen  have  made  valuable  suggestions  regarding 
the  technical  management  of  difficult  cases,  which  are  well  worthy  of 
special  mention.  Dr.  Taylor  X  at  first  draws  the  body  directly  back- 
ward while  the  head  is  forced  by  suprapubic  pressure  downward  and 
backward  into  the  pelvis.  So  soon,  however,  as  the  head  begins  to 
advance,  he  raises  the  body  of  the  child  and  directs  pressure  upon  the 
head  to  be  made  downward  and  forward  in  the  axis  of  the  outlet.  In 
case  of  failure  or  delay,  he  has  sometimes  succeeded  by  intentionally 
directing  the  back  of  the  child  to  the  sacrum,  and  then  causing  the 
occiput  to  be  pressed  downward  and  backward  into  the  nearest  sacro- 
iliac space,  with  the  face  looking  upward,  while  traction  is  made  in  the 
axis  of  the  outlet.  Dr.  Goodell,*  after  first  draAving  in  the  direction 
of  the  outlet,  with  the  assistant  pushing  downward  and  backward, 
reverses  the  direction,  and  sweeps  the  child's  body  backward  upon  the 
coccyx,  the  neck  likewise  being  forced  downward  and  backward  into 
the  hollow  of  the  sacrum  with  all  one's  power.  Where  the  projection 
of  the  promontory  is  not  very  marked,  he  likewise  recommends  as  some- 
times of  assistance  a  pump-handle  movement,  the  range  of  oscillation 
extending  from  the  axis  of  the  outlet  anteriorly  to  very  firm  jiressure 
on  the  coccyx  posteriorly. 

It  is  obvious  from  the  foregoing  description  that  version  and  ex- 
traction in  contracted  pelves  expose  the  child  to  perils  of  no  insignifi- 
cant character.  Among  the  lesions  Avhich  have  been  observed  as  a 
result  of  the  extreme  traction  force  necessary  to  bring  the  head  rapidly 
tlirough  the  narrow  brim  are  fracture  of  the  clavicles,  fracture  of  the 
humerus  in  difficult  arm-deliveries,  lacerations  of  the  sterno-cleido- 
mastoid  muscles,  rupture  through  the  substance  of  a  vertebra,  extrav- 
asations of  blood  into  the  cavities  of  the  head  and  trunk,  separation 
of  the  condyles  from  the  occiput,  and  of  the  squamous  portion  of  the 
temporal  from  the  parietal  bones,  fractures  and  depressions  of   the 

*  RoKiTANSKY,  Wieii.  med.  Presse.  1874,  No.  45. 
f  Schroeder,  Handbuch,  Gte  Aufl.,  p.  307. 

t  Taylor,  What  is  the  Best  Treatment  in  Contracted  Pelves?  p.  23. 

*  Goodell,  Clinical  Memoirs  on  Turning  in  Contracted  Pelves,  Am.  Jour,  of 
Obstet.,  A-ol.  viii,  p.  211. 


TREATMENT   OF  CONTRACTED   PELVES.  507 

skull,  and  rupture  of  the  sinuses  of  the  dura  mater.*  To  be  sure, 
many  of  these  accidents  are  not  inevitably  fatal,  but  they  do  not  by 
any  means  furnish  the  chief  sources  of  danger.  These  result  partly 
from  the  respiratory  efforts  which  are  always  excited  by  delay  in  ex- 
tracting the  after-coming  head,  and  partly  from  the  depressing  influ- 
ence exercised  uj)on  the  fetal  heart  by  pressure  brought  to  bear  upon 
the  base  of  the  brain,  f 

Having  thus  made  out,  with  great  care,  a  full  bill  of  particulars, 
embracing  all  the  acknowledged  drawbacks  to  the  j)erformance  of  ver- 
sion in  narrow  pelves,  we  have  next  to  consider  how  far  these  associ- 
ated evils  tend  to  invalidate  the  claim  of  version  to  be  regarded  as 
facile  princeps  among  conservative  measures  of  treatment.  The  fol- 
lowing records  of  the  individual  exiDerience  of  competent  operators 
will  help  us  to  solve  this  question.  Kormann  turned  in  nine  cases  of 
contracted  pelves.  Seven  children  were  born  living  and  two  dead. 
All  the  mothers  recovered. J  Lowenhardt  turned  in  twenty  cases  of 
contracted  pelves.  Seventeen  children  were  born  alive,  and  three 
dead.  Only  children  that  outlived  the  first  week  were  counted  in  the 
successful  cases.  The  mothers  recovered.*  Groodell  reports  eleven 
cases.  Seven  children  were  alive  at  birth,  and  four  were  still ;  but  of 
the  latter,  one  was  extracted  through  a  pelvis  measuring  only  two  and 
a  half  inches  conjugate  diameter,  and  in  one  the  case  was  complicated 
by  eclampsia.  The  mothers  recovered.  Now,  not  to  go  beyond  these 
forty  cases,  we  obtain,  as  the  result  of  version,  thirty-one  living  infants, 
without  the  sacrifice  of  a  single  mother.  A  number  of  the  women  in 
whose  previous  labors  craniotomy  had  been  found  necessary  were  de- 
livered by  version  of  living  children.  Lowenhardt  placed  in  contrast 
his  own  experience  Avith  the  forceps  in  narrowed  pelves  presenting 
degrees  of  contraction  corresponding  to  those  in  which  he  had  re- 
sorted to  version.  In  forty-five  deliveries,  sixteen  children  were  born 
dead  and  five  died  shortly  after  birth.  Of  the  mothers,  three  died, 
while  twenty- one  suffered  from  puerperal  affections  of  greater  or  less 
severity. 

Now,  if  the  foregoing  testimony  represented  the  entire  truth,  there 
would  be  no  good  reason  for  discussing  other  plans  of  treatment. 
They,  in  fact,  show  only  how  far  special  training  and  experience  will 
enable  an  operator  to  overcome  difficulties  by  dexterity  and  address. 
In  the  first  case  reported  by  Dr.  Goodell  the  child  was  still-born.  In 
commenting  upon  the   cause  of   death   Dr.   Goodell   states   frankly : 

*  C.  RuGE,  Verlctznngen  des  Kindcs  diirch  Extraction  bei  Beckenlage,  Ztsehr.  f. 
Geburtsh.,  Bd.  i.  p.  G8. 

f  DoHRN,  Ueber  Pulslosigkeit  des  Kindcs  wiihrend  Extraction  an  den  Filssen, 
Arch.  f.  Gynaek.,  Bd.  vi,  p.  3G5. 

X  Kormann,  Arch.  f.  Gynaek.,  Bd.  vii,  p.  13. 

*  Lowenhardt,  Wendung  und  Extraction  das  doniinirende  Yerfahren  bei  Beck- 
enenge,  Arch.  f.  Gynaek.,  Bd.  vii,  p.  4'21. 


508  THE  PATHOLOGY  OP  LABOR. 

"  Much  force  was  needed  to  extract  the  head,  but  it  was  not  made  as 
promptly  and  efficiently  as  I  have  since  learned  to  make  it."  * 

Another  side  of  the  question  has  been  presented  by  Borinski,t  who, 
at  the  instigation  of  Professor  Spiegelberg,  collected  the  statistics  of 
version  in  contracted  pelves  from  the  Breslau  Clinic  between  the  years 
1865-1872.  In  all  there  were  ninety-three  cases.  Thirty-four  chil- 
dren were  saved,  and  fifty-nine  were  born  dead,  or  died  soon  after 
birth.  Fifteen  mothers  lost  their  lives.  This  seemingly  disastrous 
showing  is  capable,  however,  to  a  certain  degree,  of  explanation.  Thus, 
twenty  of  the  fifty-nine  children  born  still  died  before  version  was 
attempted.  In  nine  of  the  cases  the  transverse  as  well  as  the  conju- 
gate was  materially  diminished.  Of  the  children  delivered  through 
these  flattened  generally  contracted  pelves,  only  one,  and  that  a  very 
small  one,  was  extracted  alive.  Still,  there  were  fifty-eight  cases  of 
version  in  ordinary  flattened  pelves,  with  the  result  that  just  one  half 
the  children  were  born  dead.  In  only  three  of  the  fifteen  mothers 
who  died  was  the  fatal  result  apparently  connected  with  the  opera- 
tion. In  the  others,  death  was  due  to  spontaneous  rupture  of  the 
uterus,  placenta  praevia,  and  nephritis,  version  having  been  resorted 
to  because  of  these  complications.  A  considerable  allowance  should 
be  made,  too,  in  the  cases  from  the  Breslau  Clinic,  for  the  fact  that 
the  greater  j^art  of  them  took  place  in  the  out-department  of  the  hos- 
pital, when  they  were  under  the  charge  of  midwives,  who  rarely  send 
for  timely  aid  except  in  the  presence  of  dangerous  complications.  In 
eighteen  instances  the  operation  was  performed  on  account  of  pro- 
lapse of  the  cord,  and  in  eighteen  instances  because  of  some  maternal 
affection. 

Forceps. — In  presenting  this  less  favorable  side  of  version  in  con- 
tracted pelves,  it  is  well  incidentally  to  place  in  juxtaposition  the  re- 
sults of  the  high  forceps  operation  as  given  by  Dr.  Harold  Williams 
(American  Journal  of  Obstetics,  January,  1879).  Williams  collected 
one  hundred  and  nineteen  cases,  reported  since  1858  where  the  forceps 
was  applied  to  the  head  above  the  brim.  Of  the  mothers  nearly  forty 
per  cent,  and  of  the  children  over  sixty  per  cent,  perished.  The  me- 
chanical objections  to  the  use  of  forceps  at  the  brim  are  obvious. 
When  the  head  is  molded  to  the  contracted  pelvis  by  the  natural 
forces,  the  head  passes  the  conjugate  with  its  long  diameter  in  the 
transverse  diameter  of  the  pelvis,  with  the  two  fontanelles  on  nearly 
the  same  level,  and  with  the  sagittal  suture  looking  toward  the  sacrum. 
The  posterior  parietal  bone  rotates  around  the  promontory,  the  latter 
producing  a  furrow,  which  runs  either  along  the  coronal  suture,  or  at 
first  in  front  of  the  parietal  boss,  and  later,  as  flexion  occurs,  forward 

*  GooDELL.  Trans,  of  the  Internat.  Med.  Congr.,  Philadelphia,  1876,  p.  777. 
t  BoRiNSKi,  Zur  Lehre  von  der  Wendung  auf  die  Fiisse  bei  engen  Becken,  Arch, 
f.  Gynaek.,  Bd.  iv,  p.  226. 


TREATMENT  OF  CONTRACTED  PELVES.  509 

toward  the  frontal  bone.  The  bilateral  compression  of  the  head  is 
compensated  for  in  part  by  a  lengthening  in  the  fronto-occipital  and 
partly  in  a  vertical  direction. 

The  forceps  applied  in  the  transverse  or  oblique  diameter  of  the 
pelvis  prevents  the  former  compensation  from  taking  place.  It  in- 
creases the  width  of  the  head,  and  thus  adds  to  the  difficulty  of  jmss- 
ing  the  conjugate.  Often  it  disturbs  further  the  normal  head  mechan- 
ism by  causing  premature  flexion  and  rotation  to  take  place.  In  each  of 
these  ways  it  augments  the  difficulties  of  delivery,  and  renders  neces- 
sary the  emi^loyment  of  an  increased  amount  of  traction  force.  With 
forceps  applied  directly  to  the  sides  of  the  child's  head  I  have  had  no 
experience,  but  Dr.  Goodell,*  who  has  clearly  pointed  out  the  objec- 
tions to  this  method  in  contracted  pelves,  has  shown  that  they  inev- 
itably produce  flexion,  and  cause  the  large  biparietal  diameter  to  j^ass 
through  the  narrow  conjugate.  So  long  as  the  head  does  not  engage 
at  the  brim,  there  is  no  rivalry  between  version  and  forceps.  The 
latter  should  be  placed  under  the  ban  as  hardly  less  dangerous  than 
the  Caesarean  section. 

Expectant  Treatment. — Now,  let  us  suppose  that  after  rupture  of 
the  membranes  it  is  decided  to  resort  to  neither  forceps  nor  version, 
but  to  adopt  an  expectant  course,  until  circumstances  arise  which  shall 
render  active  interference  necessary.  It  is  certain  that  a  very  consid- 
erable portion  of  labors  in  contracted  pelves  terminate  spontaneously. 
Winckel  f  reports  twenty-three  cases  in  the  Dresden  Maternity  in  1873, 
and  twelve  cases  in  1874-'?5.  Of  the  thirty-five  cases,  two  mothers 
and  three  children  died.  Osterloh  J  reported  one  hundred  and  thirty- 
nine  cases  from  the  Leipsic  Maternity,  between  the  years  1863-1872, 
inclusive.  There  were  one  hundred  and  five  cases  where  the  pelves 
measured  from  three  to  three  and  a  half  inches.  Of  one  hundred  and 
six  children,  seven  died.  Of  the  mothers,  four  died.  In  thirty-four 
cases  where  the  pelves  measured  over  three  and  a  half  inches,  two  chil- 
dren died.  All  the  mothers  recovered.  There  were,  however,  forty- 
two  cases  in  all  of  puerperal  disease  terminating  in  recovery.  Borinsky 
reports  from  the  Breslau  Clinic  two  hundred  and  thirty-three  spon- 
taneous deliveries  in  contracted  pelves,  with  one  hundred  and  ninety- 
two  living  children.  There  were  ten  maternal  deaths,  but  four  were 
from  non-puerperal  intercurrent  affections.  Thus,  in  three  large  ma- 
ternity hospitals  there  were  in  cases  of  contracted  pelves  four  hundred 
and  seven  spontaneous  deliveries  with  the  loss  of  fifty-three  children, 
and,  from  puerperal  diseases,  of  twelve  mothers.  ■  !^ven  in  pelves  meas- 

*  Goodell,  Labor  in  Narrow  Pelves,  Trans,  of  the  Internat.  Med.  Congr.,  Phila- 
delphia. 1876,  p.  788. 

f  Winckel,  Berichte  und  Studien,  1874-'76. 

X  Osterloh,  Einige  Beitrage  zu  den  spontan  verlaufenden  Geburten  bei  engera 
Becken,  Arch.  f.  Gynaek,  Bd.  iv,  p.  520. 


510  THE  PATHOLOGY  OF   LABOR. 

uring  less  than  three  inches,  now  and  then,  the  spontaneons  birth  of  a 
small  living  child  takes  place. 

If  we  examine  these  results,  we  find  that  under  favorable  circum- 
stances, in  all  but  the  extreme  forms  of  pelvic  contraction.  Nature 
will  do  her  own  work  with  the  least  expense  of  infant  life,  and  with  a 
relatively  small  maternal  mortality.  On  the  other  hand,  the  long-con- 
tinued pressure  upon  the  parturient  canal  incident  to  the  molding  and 
adaptation  of  the  head  to  the  narrow  pelvis,  yields  a  large  contingent 
of  inflammatory  affections,  which  complicate  the  puerperal  period  and 
protract  the  convalescence.  By  favorable  circumstances  Ave  mean  a 
presentation  and  position  of  the  child's  head  suited  to  the  form  of  the 
pelvis,  and  a  sufficient  degree  of  uterine  activity.  Rectification  of  a 
faulty  position  of  the  head  after  the  rupture  of  the  membranes  is 
always  a  matter  difficult  of  accomplishment.  In  case,  therefore,  the 
brow  presents,  or  the  head  engages  with  an  excessive  degree  of  lateral 
obliquity  (sagittal  suture  looking  forward  toward  the  pubes,  or  back- 
ward toward  the  promontory),  in  place  of  wasting  time  in  futile  efforts 
at  correcting  the  malposition,  version  should  be  promptly  performed. 
In  prolapse  of  the  cord,  which  pccurs  in  about  six  per  cent,  of  the 
cases,  the  indication  would  clearly  be  version  rather  than  replacement. 
In  eclampsia  and  face  presentations  most  operators  would  preferably 
resort  to  version. 

Thus,  we  have  finally  the  field  of  controversy  between  version  and 
other  plans  of  treatment  narrowed  down  to  cases  in  which,  after  rupt- 
ure of  the  membranes,  the  head  remains  above  the  brim,  but  the  con- 
ditions are  such  that  Nature  is  capable  of  overcoming  the  mechanical 
difficulties  of  delivery  providing  that  the  labor-pains  are  sufficiently 
energetic.  There  is  always  an  element  of  chance  in  this  last  condition, 
which,  however,  is  an  essential  one.  If  the  pains  are  weak  and  pow- 
erless, it  may  be  possible,  even  hours  after  rupture  of  the  membranes, 
when  the  head  has  not  become  fixed,  to  still  accomplish  version.  More 
frequently,  however,  as  the  head  but  incompletely  fills  the  lower  seg- 
ment of  the  uterus,  the  waters  escape,  the  uterus  retracts  upon  the 
feetus,  the  cervix  becomes  oedematous  and  tender,  and  after  a  time 
the  temperature  and  pulse  rise,  betokening  the  presence  of  danger. 
Sometimes  the  retraction  of  the  uterus  ends  in  the  withdrawal  of  the 
cervix  over  the  child's  head,  and,  in  the  failure  of  the  latter  to  de- 
scend into  the  pelvis,  the  vagina  is  drawn  upward,  and  subjected  to  a 
perilous  degree  of  ^tension.  It  is  easy  to  see  that  under  such  cir- 
cumstances the  time  for  version  is  past,  and  craniotomy  is  called  for. 
Because,  therefore,  where  labor  is  left  in  contracted  pelves  to  the  spon- 
taneous efforts  of  Nature,  in  a  certain  proportion  of  cases  the  insuf- 
ficiency of  the  labor-pains  leads  to  the  necessity  of  sacrificing  the 
child,  there  will  always  be  operators  who,  confident  in  their  own  skill, 
will  prefer  to  turn  soon  after  rupture  of  the  membranes,  that  they  may 


TREATMENT  OF  CONTRACTED  PELVES.  5H 

keeja  in  their  hands  the  control  of  the  delivery.  The  bulk  of  pro- 
fessional men  will,  on  the  contrary,  so  long  as  spontaneous  delivery 
is  probable,  prefer  to  wait,  even  though  by  so  doing  they  may  eventu- 
ally find  themselves  obliged  to  fall  back  upon  the  perforator  and  the 
crotchet. 

AVhen  the  birth  of  the  child  is  left  to  the  contractions  of  the 
uterus,  re-enforced  by  the  expiratory  muscles,  the  physician  should 
assume  the  role  of  a  watchful  spectator.  Safety  to  the  mother  and 
the  child  requires  that  the  time  of  the  passage  of  the  head  through  the 
bony  canal  should  not  be  too  prolonged.  So  long  as  the  head  de- 
scends steadily,  however  slow  the  progress  may  be,  in  case  no  compli- 
cations demand  speedy  extraction,  the  physician  should  await  the 
results  of  uterine  activity.  Should  the  pains  grow  weak  and  inef- 
ficient, they  may  be  stimulated  by  the  uterine  douche,  the  introduc- 
tion of  the  catheter  into  the  uterus,  and  by  small  doses  of  ergot  or  the 
viscum  album,  provided  the  inertia  is  not  the  result  of  pathological 
changes  in  the  uterine  tissues. 

When  the  advance  of  the  head  ceases,  either  from  failure  of  the 
pains  or,  as  in  justo-minor  pelves,  from  the  growing  resistance  of  the 
pelvic  outlet,  the  rule  should  be  to  relieve  the  soft  parts  of  the  mother 
as  speedily  as  possible  from  the  pressure  of  the  child's  head.  Press- 
ure too  long  continued  ends  in  cedematous  swelling,  softening  of  the 
tissues,  arrest  of  circulation,  and  eventually  in  necrosis  and  gangrene. 
When  the  integrity  of  the  lower  segment  of  the  uterus  has  been  im- 
paired to  any  extent,  perforation  should  be  resorted  to,  and  the  child 
sacrificed  to  the  interests  of  the  mother.  If,  on  the  contrary,  the 
changes  are  insignificant,  and  the  mechanical  difficulties  not  insuper- 
able, by  the  use  of  forceps  it  may  be  possible  to  save  the  life  of  both 
mother  and  child.  But  to  avoid  the  first-named  cruel  alternative,  the 
forceps  should  be  applied  so  soon  as  the  requisite  conditions  for  its 
employment  are  reached.  Of  course,  as  the  forceps  is  used  solely  to 
save  fetal  life,  in  case  the  feeble  heart-action  of  the  child  gives  warn- 
ing of  impending  asphyxia  the  interests  of  the  mother  are  to  be  alone 
consulted. 

In  estimating  the  mechanical  difficulties  to  be  overcome  by  the 
forceps,  it  is  necessary  to  determine  how  far  engagement  has  taken 
place,  Litzmann  *  recommends  that  the  physician  ascertain  by  inter- 
nal examination,  combined  with  external  palpation,  both  the  size  of 
the  segment  of  the  cranium  below  the  brim  and  how  much  of  the 
head  remains  to  undergo  compression  before  it  can  enter  the  j)elvis. 

In  ordinary  flattened  pelves,  Litzmann  found  that  in  three  fourths 
of  all  the  cases  the  pains  alone  sufficed  to  overcome  the  resistance  of 
the  brim.    W^hen  the  head  had  so  far  descended  that  the  sagittal  suture 

*  LiTZMANx,  Ueber  die  Behandlung  der  Geburt  bei  engem  Becken,  Volkniann's 
Samral.  klin.  Vort.,  pp.  715  et  seq. 


512  THE  PATHOLOGY  OF  LABOR. 

had  passed  from  three  to  four  fifths  of  an  inch  below  the  promontory, 
and  the  boss  of  the  anterior  parietal  bone  could  be  felt  with  ease 
behind  the  symphysis  pubis,  extraction  with  the  forceps  was  a  task  of 
no  great  difficulty,  even  if  before  its  application  flexion  had  not  begun 
to  take  place. 

In  generally  contracted  flattened  pelves,  it  is  desirable  that  the 
head  should  be  transverse  and  well  flexed,  with  the  posterior  parietal 
bone  at  least  three  fifths  of  an  inch  below  the  promontory.  With  the 
forehead  and  occiput  resting  upon  the  side  walls  of  the  pelvis,  the 
sagittal  suture  near  the  promontory,  and  an  ear  felt  behind  the 
symphysis  pubis,  the  prospects  of  forceps  operations  are  extremely 
dubious. 

In  justo-miuor  pelves  of  moderate  extent  (conjugate  three  and  a 
half  inches),  the  failure  of  the  pains,  which  forms  the  necessity  for 
forceps,  is  rather  the  result  of  the  paralyzing  effect  of  the  pressure  of 
the  bony  canal  upon  the  entire  circumference  of  the  cervix  than  of 
the  absolute  degree  of  pelvic  contraction.  The  head  descends  in  a 
state  of  comj)lex  flexion,  with  the  large  fontanelle  at  the  pelvic  brim. 
If,  as  the  head  advances,  the  small  fontanelle  moves  from  the  median 
line,  and  the  large  fontanelle  becomes  accessible  to  the  finger,  it  is 
likely  that  the  pelvis  widens  toward  the  outlet.  If  the  forceps  serves 
only  to  bring  the  fontanelle  down  still  deeper,  and  to  increase  the  de- 
clivity of  the  sagittal  suture,  the  opposite  condition  obtains,  which  may 
frustrate  the  delivery.* 

In  flattened  pelves  the  forceps  should  be  applied  as  nearly  as  pos- 
sible to  the  fronto-occipital  diameter  of  the  head,  as  the  latter  needs 
to  descend  into  the  transverse  diameter  of  the  pelvis.  When  applied 
obliquely  it  tends  to  cause  premature  rotation,  which  increases  the 
difficulties  of  extraction.  In  justo-minor  pelves  the  direction  of  the 
blades  is  of  less  importance,  as  the  head  often  descends  sjiontaneously 
in  an  oblique  diameter.  Success  in  high  forceps  operations  depends 
upon  the  degree  of  accuracy  with  which  the  tractions  are  made  in  the 
axis  of  the  pelvis.  With  the  long-curved  forceps,  it  is  especially  diffi- 
cult to  fulfill  this  requirement  at  the  superior  strait.  Even  when  the 
directions  to  draw  vertically  downward  are  faithfully  carried  out,  a 
considerable  portion  of  the  force  is  expended  in  the  pressure  of  the  for- 
ceps upon  the  soft  tissues  lying  between  them  and  the  anterior  pelvic 
wall.  In  careless  hands  this  pressure  is  capable  of  inflicting  a  great 
deal  of  injury,  particularly  where  the  blades  of  the  forceps  are  passed 
within  an  imperfectly  dilated  cervix,  and  where  they  project  somewhat 
beyond  the  child's  head.  Various  devices  have  been  invented  to  cor- 
rect this  defective  working  of  the  instrument.  Pajot  recommends 
placing  the  left  hand  upon  the  lock  to  make  pressure  backward,  while 
with  the  right  hand  tractions  are  made  downward  and  somewhat  for- 
*  LiTZMAXN,  Ueber  die  Behandlunjr  der  Geburt  bei  enerem  Becken. 


TREATMENT  OF  COI^TR ACTED  PELVES.  513 

ward.  I  have  generally  succeeded  by  exerting  a  small  amount  only  of 
force  at  each  traction,  watching  at  the  same  time  with  great  care  the 
direction  of  the  blades  in  the  pelvis.  This  method  is  pretty  safe,  and 
in  the  end  generally  successful,  but  often  requires  a  very  considerable 
outlay  of  time  and  patience.  A  pair  of  straight  forceps,  as  recom- 
mended by  Dr.  I.  E.  Taylor,  will  often  enable  one  to  draw  more  di- 
rectly in  the  axis  of  the  brim,  and  will  succeed  when  the  curved  for- 
ceps have  had  to  be  abandoned.  Of  late  I  have  been  in  the  habit  of 
using  Tarnier  forceps  in  high  operations,  and  am  able  to  give  it  my 
cordial  approval.  The  blades  always  swing  in  the  transverse  diameter 
of  the  pelvis,  while  the  traction  force  is  exerted  as  nearly  as  possible 
upon  the  center  of  the  child's  head.  A  few  trials  will  convince  the 
most  prejudiced  opponent  of  the  Tarnier  forceps  that  it  will  at  the 
superior  strait  bring  the  head  to  the  floor  of  the  pelvis  in  much  less 
time,  and  with  a  less  expenditure  of  force,  than  can  be  accomplished 
by  other  methods. 

The  dangers  from  the  forceps  in  contracted  pelves  are  due  not 
so  much  to  the  pressure  it  makes  directly  upon  the  child's  head  and 
the  pelvic  walls  as  to  the  compensatory  bulging  of  the  head  in  its 
transverse  diameter.  When  the  head  is  fixed  at  the  brim  and  the  for- 
ceps is  applied  to  the  forehead  and  occiput,  it  is  evident  that  the  only 
change  of  form  that  can  take  place  is  in  a  vertical  direction.  Safety 
in  delivery  requires  that  there  should  be  no  sudden  augmentation  of 
the  bilateral  pressure,  which  would  necessarily  deepen  the  farrow  made 
by  the  promontory  upon  the  posterior-lying  parietal  bone,  and  im- 
peril the  integrity  of  the  maternal  tissues  confined  at  the  conjugate 
between  the  promontory  and  the  pubes.  Until,  therefore,  the  head 
has  passed  the  narrow  strait,  tractions  should  be  made  with  moderate 
force,  and  with  short  periods  of  intermittence.  After  the  head  has 
once  descended  to  the  floor  of  the  pelvis  the  forceps  should  be  removed, 
and  the  head  be  allowed  to  rotate  into  the  conjugate,  then  a  forceps  of 
any  pattern  may  be  adjusted  to  the  sides  of  the  head,  should  further 
aid  be  required  to  complete  delivery. 

So  far  we  have  considered  cases  in  which  the  cervix  was  suf- 
ficiently if  not  completely  dilated  before  rupture  of  the  membranes. 
If,  as  is  very  common,  the  membranes  rupture  prematurely,  the  diffi- 
culties and  risks  to  both  mother  and  child  are  greatly  increased.  With 
rupture  come,  as  we  have  already  seen,  escape  of  the  amniotic  fluid, 
retraction  of  the  uterus,  and  interference  in  the  utero-placental  cir- 
culation. With  an  undilated  os  externum  the  cervix  is  stretched  by 
the  head,  and  its  thinned  tissues  are  subjected  to  pressure  from  the 
symphysis  and  promontory.  Delay  leads  to  arrest  of  circulation  and 
necrosis  at  the  points  of  pressure,  but  here  version  and  forceps  are 
alike  impracticable.  This  leaves  as  the  only  alternatives  perforation 
and  the  Cassarean  section.  Timely  aid,  therefore,  in  such  cases  should 
33 


514 


THE  PATHOLOGY  OF   LABOR. 


be  extended  before  a  dangerous  condition  is  reached.  My  first  prefer- 
ence just  after  rupture  is  the  Barnes  dilator,  which  not  only  serves  to 
expand  the  cervix,  but,  when  employed  promptly,  helps  to  prevent 
the  escape  of  the  amniotic  fluid.  Next  to  the  Barnes  dilator,  and  of 
special  utility  when  the  waters  have  already  escaped,  I  would  place 
the  long,  narrow-bladed  forceps  of  Dr.  Taylor  for  introduction  through 
the  undilated  os.  With  it  the  head  can  be  grasped,  and,  when  made 
to  descend  and  then  allowed  to  recede  in  alternation,  oftentimes  the 
rounded  cranial  surface  will  efficiently  act  as  a  dilating  body,  and  se- 
cure such  a  degree  of  expansion  as  will  pave  the  way  for  the  safe  adop- 
tion of  other  methods  of  delivery. 


CHAPTER  XXVII. 

RARE  FORMS  OF  PELVIC  DISTORTION. 

The  Naegele  oblique  pelvis :  morbid  anatomy,  etiology,  diagnosis,  mechanism  of 
labor  in,  prognosis,  treatment.— The  kyphotic  pelvis :  morbid  anatomy,  etiology, 
diagnosis,  prognosis.— Scolio-rachitic  pelvis:  anatomical  characters. — Robert's 
pelvis :  anatomy,  etiology,  diagnosis,  prognosis. — Spondylolisthetic  pelvis :  an- 
atomical characters,  diagnosis,  prognosis.— Funnel-shaped  pelvis. — Osteoma- 
lacia.— Pelvis  narrowed  by  exostoses. — Divided  symphysis. 


I.  The  Naegele  Oblique  Pelvis. 

This  variety  of  deformed  pelvis  derives  its  name  from  the  author 
who  first  systematically  studied  it  and  called  attention  to  its  impor- 
tance as  a  cause  of  obstructed  labor. 

Morbid  Anatomy. — The  pathological  characters  peculiar  to  this  va- 
riety of  deformed  pelvis  are,  according  to  the  classical  description  of 
Naegele,*  the  following :  1.  Complete  anchylosis  of  one  sacro-iliac 
synchondrosis,  or  osseous  union  between  the  sacrum  and  one  os  innomi- 
natum.  2.  Destruction  or  defective  development  of  the  lateral  half  of 
the  sacrum  and  smaller  caliber  of  the  anterior  sacral  foramina  on  the 
anchylosed  side.  3.  Diminished  breadth  of  the  os  innominatum  and  of 
the  sacro-sciatic  notches  on  the  same  side.  The  articular  facet  of  the  ili- 
um, which  corresponds  to  the  sacral  auricular  surface,  is  less  elongated 
than  on  the  non-anchylosed  side.  4.  The  sacrum  is  displaced  toward 
the  anchylosed  side,  and  its  anterior  surface  is  turned  in  that  direction. 
The  pubic  symphysis  is  pushed  to  the  healthy  side,  and  is  therefore 
not  directly  opposite  the  promontory.  5.  The  internal  surface  of  the 
OS  innominatum  on  the  deformed  side  is  flatter  than  the  correspond- 
ing sound  bone,  and  the  linea   ilio-pectinea   is  but   slightly   curved. 

*  Naegele,  "  Das  schragverengtes  Beckcn,"  Mainz,  1850,  p.  7. 


RARE  FORMS  OF  PELVIC  DISTORTION. 


515 


6.  The  sound  side  of  the  pelvis  is  not  of  an  entirely  natural  shape,  as 
is  shown  by  the  fact  that  its  ilio-pectineal  line  is  straighter  posteriorly, 
and  more  curved  anteriorly,  than  in  a  normal  pelvis.  ?.  The  results 
of  the  deformities  mentioned  are  : 

(a)  That  the  pelvis  is  contracted  in  that  oblique  diameter  meas- 
ured by  a  line  passing  from  the  acetabulum  of  the  anchylosed  side  to 
the  opposite  sacro-iliac  joint,  while  the  other  oblique  diameter  is  not 
shortened,  but  even  elongated  in  extreme  cases,  (b)  That  the  dis- 
tances between  the  promontory  and  either  acetabulum,  and  those  be- 
tween the  apex  of  the  sacrum  and  the  spine  of  either  ischium,  measured 
from  the  affected  side,  are  less  than  the  corresponding  distances  on  the 
other,  (c)  That  the  distances  between  the  tuber  ischii  of  the  anchy- 
losed side  and  the  posterior  superior  spinous  process  of  the  opbosite 
ilium,  and  those  between  the  spine  of  the  last  lumbar  vertebra  and  the 
anterior  superior  spinous  process  of  the  diseased  side,  are  shorter  than 
the  corresponding  distances  on  the  opposite  side,  (d)  That  the  distance 
of  the  superior  posterior  iliac  spine  of  the  anchylosed  side  from  the 
lower  border  of  the  symphysis  pubis  is  greater  than  that  between  the 


Fia.  213.— Naegele  oblique  pelvis.    (From  specimen  in  the  Wood  Museum.) 

symphysis  and  the  opposite  posterior  superior  spinous  process,  (e)  That 
the  walls  of  the  pelvic  cavity  converge  below,  and  that  the  pubic  arch 
is  narrowed  and  approximated  to  the  type  of  the  male  arch.  (/)  That 
the  acetabialum  of  the  flattened  side  is  directed  farther  forward  than  is 
normal,  while  the  opposite  acetabulum  looks  almost  directly  outward. 
We  may  add  that  the  anterior  surfaces  of  the  bodies  of  the  lumbar  ver- 
tebrae are  directed  toward  the  anchylosed  side.  The  ilium  is  higher, 
steeper,  flatter,  and  reaches  farther  backward  on  that  side.  The  pubic 
arch  looks  toward  the  flattened  side.  The  conjugata  vera  is  somewhat 
elongated.  The  transverse  diameter  is  shortened  at  the  inlet,  and  its 
shortening  progressively  increases  as  the  outlet  is  approached.*     The 

*  ScHROEDER,  Lehrb.,  p.  596. 


516  THE  PATHOLOGY  OP  LABOR. 

OS  innominatum  of  the  healthy  side  is  somewhat  displaced  outward, 
and  is  more  markedly  curved,  hence  the  venter  of  the  corresponding 
ilium  is  directed  more  anteriorly  than  that  of  the  anchylosed  side.* 
The  deformity  is  most  apparent  at  the  inlet,  which  is  compared  by 
Naegele  to  an  oblique  oval  figure.  The  tuber  ischii  on  the  anchylosed 
side  is  higher,  and  directed  more  posteriorly  and  internally  than  nor- 
mal. This  description  will  also  apply  to  the  ordinary  oblique-ovate 
pelvis,  except  so  far  as  the  anchylosis,  which  is  the  distinguishing 
feature  of  the  Naegele  oblique,  is  concerned. 

Etiology.— The  essential  cause  of  oblique-ovate  pelvis  in  general 
is  continuous  pressure  directed  against  one  of  its  lateral  halves,  the 
weight  of  the  trunk  falling  predominantly  or  exclusively  upon  the 
lower  extremity  of  the  deformed  side,  and  leading  to  displacement  and 
distortion  of  the  pelvic  bones.  The  conditions  producing  this  pre- 
dominant unilateral  pressure  are  tabulated  by  Litzmann  f  as  follows : 
1.  Lateral  spinal  curvature,  usually  of  rachitic  origin.  2.  Impeded  or 
entirely  abrogated  function  of  one  lower  extremity.  In  this  case  the 
deformity  will  affect  that  side  the  lower  extremity  of  which  is  intact.  J 
The  impairment  or  loss  of  function  may  result— (r?)  from  unilateral 
hip-disease ;  {b)  from  amputation  of  one  lower  extremity ;  (c)  from 
an  old  dislocation  of  the  femur  upward  and  backward.  3.  Unsym- 
metrical  sacrum,  produced  by  defective  development,  or  by  atrophy  of 
one  sacral  lateral  mass — (a)  as  the  result  of  a  defect  in  the  original 
formation ;  (b)  as  the  result  of  abnormal  coalescence  of  the  sacrum 
and  ilium  in  early  life,  whereby  the  growth  of  both  was  hindered ;  (c) 
as  the  result  of  a  loss  of  substance  from  caries.  Spiegelberg  **  calls 
attention  to  Lambl's  statement  that  primary  asymmetry  of  the  sa- 
crum may  be  due  to  coalescence  of  the  sacral  lateral  masses  and  the 
transverse  processes  of  the  last  lumbar  vertebra,  whereby  the  outward 
growth  of  the  former  is  impeded.  He  also  emphasizes  ||  the  fact  that 
simple  chronic  arthritis  of  the  sacro-iliac  synchondrosis  produces  sa- 
cral asymmetry,  without  anchylosis,  by  inducing  contraction  and  atro- 
phic sclerosis  of  the  contiguous  osseous  tissue.  The  continued  use  of 
one  shortened  lower  extremity  is  another  cause  of  excessive  pressure 
upon  the  corresponding  side  of  the  pelvis.  When  this  condition  ob- 
tains, the  deformity  will  be  on  the  side  of  the  shortening.  The  sacro- 
iliac synostosis,  which  has  been  alluded  to  as  the  distinguishing  char- 
acteristic of  the  Naegele  oblique,  as  contrasted  with  the  other  forms  of 
the  olbique-ovate  pelvis,  is  sometimes  the  primary  defomity,  as  will  be 
seen  from  the  foregoing  etiological  table.     The  coalescence  of  the  joint- 

*  Litzmann,  Die  Pormen  d.  Beckens,  Berlin,  1861,  p.  G9. 
t  Litzmann,  op.  cif.,  p.  68. 

t  GussEROw,  Arch.  f.  Gj-naek.,  Bd.  xi,  1877,  p.  264. 

*  Spiegelberg,  Lehrb..  p.  475. 

II  Spiegelberg,  Arch.  f.  Gynaek.,  ii,  1871.  pp.  159  et  ssq. 


RARE  FORMS  OF  PELVIC  DISTORTION.  517 

surfaces  is  never,  however,  congenital,  because  the  articulation  is  fully 
formed  before  the  appearance  of  the  centers  of  ossification  for  the  sa- 
cral lateral  masses.  Nor  can  the  synostosis  be  referred  to  involvement 
of  the  joint-surfaces  in  the  process  of  ossification,  since  this  does  not 
occur  in  any  true  joint.  The  disappearance  of  the  joint-cavity  must, 
therefore,  be  referable  to  an  inflammatory  process,  resulting  in  adhe- 
sion of  the  opposed  articular  surfaces.  The  inflammation  may  be  either 
of  traumatic  or  of  strumous  origin.  The  results  of  unilateral  pressure 
upon  the  pelvis  will  depend  upon  the  amount  of  pressure  exerted,  the 
resistance  of  the  bones,  and  the  firmness  of  their  connections. 

Diagnosis. — The  attention  of  the  obstetrician  will  be  directed  to 
the  possibility  of  the  existence  of  the  oblique-ovate  pelvis  when  the 
subject  limps  and  presents  an  inequality  in  the  height  of  the  hips  or 
evidences  of  antecedent  gluteal  abscesses.  The  diagnosis  is  assured  by 
a  physical  examination,  which  shows,  in  the  first  place,  the  distance 
between  the  spinous  process  of  the  last  lumbar  vertebra  and  the  pos- 
terior superior  spinous  process  to  be  considerably  less  on  the  deformed 
than  on  the  healthy  side.  The  absence  of  this  sign  is,  however,  no 
proof  of  the  non-existence  of  the  deformity.  The  distorted  ilium  is 
higher  than  the  other,  and  projects  farther  posteriorly  than  is  normal. 
A  vaginal  examination  reveals  the  straight  course  of  the  ilio-pectineal 
line  on  the  side  of  the  anchylosis,  the  deviation  of  the  subpubic  arch 
toward  that  side,  a  disparity  in  the  distances  between  the  ischiatic 
spines  and  the  apex  of  the  sacrum,  and  the  deviation  of  the  promon- 
tory. Naegele  *  suggested,  for  the  completion  of  the  diagnosis,  the 
application  of  the  following  measurements,  Avhich  are  equal  on  both 
sides  in  the  normal,  but  different  in  the  oblique-ovate  pelvis :  1.  The 
distance  of  the  tuber  ischii  of  one  side  from  the  posterior  superior 
iliac  spine  of  the  other ;  on  the  deformed  side  it  is  shorter.  2.  That 
from  the  anterior  superior  to  the  posterior  superior  spine  of  the  other 
side ;  shorter  from  the  anterior  spine  of  the  deformed  side.  3.  That 
from  the  spine  of  the  last  lumbar  vertebra  to  the  anterior  superior 
spinous  process  of  the  same  side ;  less  on  the  contracted  side.  4.  That 
from  the  trochanter  major  to  the  opposite  posterior  superior  spinous 
process ;  shorter  when  measured  from  the  affected  side.  5.  That  from 
the  under  surface  of  the  symphysis  pubis  to  the  posterior  sujoerior 
iliac  spine;  longer  on  the  narrowed  side.  These  measurements  are 
only  of  avail  in  well-mark^ed  cases,  and  may  lead  to  erroneous  con- 
clusions if  other  diseases  of  the  bones  be  simultaneously  present. 
The  vaginal  examination  affords,  on  the  whole,  the  most  accurate 
results. 

Mechanism  of  Labor. — The  mechanism  of  the  birth,  in  an  oblique- 
ovate  pelvis,  is  the  following :  If  the  promontory  be  retreating,  the 
sagittal  suture  of  the  fetal  cranium  enters  the  inlet  parallel  to  the 
*  Naegele,  op.  cif.,  p.  174. 


518 


THE  PATHOLOGY  OF  LABOR. 


longer  oblique  diameter.  If,  however,  the  promontory  project  con- 
siderably, and  is  closely  approximated  to  the  ilium  of  the  affected  side, 
no  portion  of  the  head  can  be  admitted  between  them.*  The  cranium 
will  then  enter  the  pelvis  most  easily  with  the  sagittal  suture  in  the 
short  oblique  diameter,  and  will  pass  through  tbe  pelvic  canal  without 
rotation.  If  the  pelvis  be  originally  small  and  the  deformity  marked, 
the  obstruction  to  labor  may  be  complete.  Should  the  pelvis,  how- 
ever, be  roomy  and  the  promontory  retreating,  no  considerable  impedi- 
ment will  be  offered  to  parturition. 

Prognosis. — It  is  obvious  that  the  prognosis,  for  both  mother  and 
cliild,  is  best  when  the  pelvis  was  originally  large,  and  far  less  favor- 
able under  the  reversed  condition.  In  the  latter  case  the  mother  very 
frequently  succumbs  and  the  child  is  only  rescued  by  the  Cesarean 
section.  Litzmann's  f  statistics  report  the  death  of  twenty-two  out  of 
twenty-eight  mothers,  five  of  whom  perished  undelivered,  and  that  of 
thirty-one  children  out  of  forty-one  cases.  These  figures  by  no  means, 
however,  fairly  represent  the  average  result,  since  many  cases  of  slight 
and  moderate  deformity  escape  detection. 

Treatment. — In  a  case  of  extreme  obliquity  at  the  Bellevue  Hospi- 
tal, Avhere  the  distance  between  the  ischia  barely  exceeded  two  inches, 
I  induced  premature  labor  at  presumably  the  twenty-ninth  week.  The 
child  was  turned  and  lived  long  enough  after  extraction  to  receive 
the  rite  of  baptism.  The  mother  made  a  speedy  recovery.  This  case 
affords  a  striking  contrast  to  those  reported  by  Litzmann.  Undoubt- 
edly, if  the  obliquity  were  always  recognized  at  a  sufficiently  early 
period  of  pregnancy,  the  induction  of  premature  labor  would  favorably 
change  the  prognosis.  Very  commonly,  however,  the  condition  passes 
unperceived  until  delay  in  labor  leads  to  a  more  careful  investigation. 
In  such  cases,  if  the  head  has  entered  the  pelvic  cavity,  and  the  dimi- 
nution of  the  space  between  the  ischia  is  not  excessive,  a  careful  at- 
tempt should  be  made  with  the  forceps  to  test  the  adaptability  of  the 
presenting  part  to  the  contracted  diameter.  Violent  tractions  should, 
however,  be  avoided.  Studley  J  has  recently  reported  a  case  of  coxal- 
gic  oblique  pelvis  in  which  fracture  of  the  pubic  rami  upon  the  right 
side  resulted  from  forceps  delivery.  If  the  disproportion  is  such  that 
moderate  tractions  are  unavailing  to  advance  the  head,  or  if  the  child 
is  already  dead,  perforation  should  be  performed.  Craniotomy  at  the 
inferior  strait  is  much  less  dangerous  than  ^t  the  brim. 

If  the  head  fail  to  enter  the  pelvis,  we  have  to  inquire  whether  the 
result  be  due  to  absolute  deficiency  of  the  pelvic  space,  or  to  the  fact 
that  the  sagittal  suture  of  the  head  corresponds  to  the  shortened  ob- 
lique diameter.  In  the  first  event  the  case  becomes  a  suitable  one  for 
Caesarean  section,  while  in  the  second  version  should   be  performed 

*  Litzmann.  Monatsschr.  f.  Geburtsk..  xxiii,  1864,  p.  268. 
t  Ibid.,  p.  284.  X  -^m.  Jour,  of  Obstet.,  1879,  p.  269. 


RARE  FORMS  OP  PELVIC  DISTORTION. 


519 


with  a  view  to  bringing  the  long  cephalic  diameter  into  correspond- 
ence with  the  opposite  longer  diameter  of  the  pelvis.  If  extraction  is 
then  fonnd  to  be  impossible,  perforation  can  still  be  performed  upon 
the  after-coming  head. 

11.   The  Kyphotic  Pelvis. 

Morbid  Anatomy. — The  characteristic  deviations  of  a  kyphotic  pel- 
vis from  the  normal  type  are  due  to  the  unnatural  direction  in  which 
the  weight  of  the  superimposed  trunk  is  communicated  to  the  base  of 
the  sacrum,  as  the  result  of  an  existing  antero-posterior  spinal  cur- 
vature. If  a  dorsal  kyphosis  be  entirely  compensated  by  a  lumbar 
lordosis,  the  former  may 
entail  no  pelvic  distortion. 
As  a  rule,  the  deformity  is 
most  marked  with  lumbar 
and  sacral  kyphoses,  which 
admit  of  no  compensatory 
lordosis,  and  least  apparent 
with  remote  dorsal  kyphoses. 
The  effect  of  the  altered  di- 
rection, in  which  the  weight 
of  the  trunk  is  transmitted 
to  the  sacrum,  is  to  force  the 
latter  more  deeply  between 
the  ossa  innominata  and  to 
rotate  its  upper  portion  in 
a  posterior  direction.  The 
displacement  backward  of 
the  inferior  extremity  of  the 
trunk  causes  the  center  of 
gravity  to  be  thrown  far 
behind  the  acetabula,  and 
produces  a  consequent  dimi- 
nution in  the  obliquity  of  the  pelvis  by  elevating  the  anterior  pelvic 
parietes.*  The  change  in  the  pelvic  obliquity  is  antagonized  by  the 
ilio-femoral  ligaments,  and  the  result  of  these  opposing  forces  is  as 
follows :  The  sacrum  is  narrowed  and  elongated  by  the  traction  from 
behind  and  above,  and  its  upper  part  is  displaced  backward.  Its 
transverse  concavity  is  increased  and  its  longitudinal  concavity  dimin- 
ished, f  The  bodies  of  the  sacral  vertebrae  are  on  a  plane  posterior  to 
their  transverse  processes.  The  promontory  is  high  and  is  directed 
far  backward.  The  upper  anterior  surface  is  sometimes  convex  while 
the  concavity  of  the  lower  part  is  preserved,  and  an  S-like  shape  is 

*  Laxge,  Arch.  f.  Gynaek.,  Bd.  i,  1870,  p.  231. 

f  Breslau,  Monutsschr.  f.  Geburtsk.,  Bd.  xxvii,  18C6,  p.  319. 


Fia.  214.— Specimen  of  kyphotic  pelvis.    (Litzmaim.) 


520 


THE  PATHOLOGY  OF  LABOR. 


thus  imparted  to  the  sacral  curve.  The  higher  anterior  sacral  foram- 
ina look  upward.  Owing  to  the  tension  of  the  ilio-femoral  ligaments, 
the  anterior  inferior  spinous  processes  of  the  ilium  are  well  developed. 
The  linecB  iUo-pectinecB  are  only  slightly  curved.  The  subpubic  arch 
is  narrowed.  The  spines  and  tuberosities  of  the  ischia  are  abnormally 
approximated.  Owing  to  the  narrowness  of  the  sacrum,  the  posterior 
superior  iliac  spines  are  in  close  proximity  to  each  other,  while  the 
spines  and  crest  of  the  ilium  are  more  remote  than  in  a  normal  pelvis. 
The  venters  of  the  ilia  are  expanded  and  directed  to  the  front.  The 
transverse  diameter  of  the  false  pelvis  is  therefore  increased,  while  that 
of  the  true  pelvis  is  diminished.  The  symphysis  is  prominent,  the 
horizontal  pubic  rami  meeting  at  an  acute  angle.  At  the  inlet  the 
oblique  and  the  conjugate  diameters  are  elongated  and  the  transverse 
diameter  curtailed.  In  the  true  pelvis  the  transverse  diameters  are  con- 
siderably and  the  antero-posterior  diameter  slightly  shortened.  These 
diameters  become  still  more  contracted  as  the  outlet  is  approached.* 
If  a  lumbo-sacral  kyphosis  be  present,  the  sacrum  is  shortened  and 
very  narrow.  If  this  kyphosis  be  situated  very  low  down,  it  may  be 
compensated  for  by  a  low  lumbar  lordosis,  which  overhangs  and  ma- 
terially contracts,  the  pelvic  inlet,  f 

Etiology. — The  cause  of  the  spinal  curvature  resulting  in  kyphotic 
pelvis  is  usually  caries  of  the  vertebrae. 

Diagnosis. — The  antecedent  history  and  the  discovery  of  kyphosis 
will  render  the  existence  of  this  form  of  pelvis  prooable.  On  more 
careful  physical  examination,  the  shape  and  position  of  the  sacrum, 
the  short  interval  between  the  spines  and  the  tuberosities  of  the  is- 
chium and  the  posterior  superior  iliac  spines,  the  wide  separation  of  the 
anterior  superior  iliac  spines,  the  narrow  pubic  arch  and  prominent 
symphysis,  the  flatness  of  the  iliac  venters,  and  the  difficulty  experi- 
enced in  reaching  the  promontory,  will  establish  the  diagnosis.  The 
differential  diagnosis  between  a  kyphotic  pelvis  and  one  deformed  by 
osteomalacia,  with  which  it  is  sometimes  confounded,  will  be  readily 
made  by  reference  to  these  distinctive  features  and  to  the  fact  that 
the  transverse  diameters  of  the  false  pelvis  are  elongated  in  a  kyphotic 
pelvis,  the  reverse  obtaining  in  osteomalacia. 

Prognosis. — The  amount  of  obstruction  offered  to  parturition  will 
naturally  depend  upon  the  grade  of  the  pelvic  contraction.  The 
prospects  for  the  preservation  of  the  child's  life  are  not  very  favorable. 
In  some  instances,  as  in  a  case  reported  by  Korsch,J  there  existed  a 
considerable  amount  of  mobility  in  the  pelvic  joints,  which  permits  an 
enlargement  of  the  outlet  and  facilitates  the  parturient  process.     The 

*  HuTER,  Ztschr.  f.  Geburtsh.  u.  Gynaek.,  Bd.  v,  1880,  p.  22. 
t  Feeling,  Arch.  f.  Gynaek.,  Bd.  iv,  1872,  p.  2. 

X  EoRSCH,  Ein  wahrend  der  Gebnrt  constatirter  Fall  von  Beweglichkeit  der 
Gelenkverbindungen  des  kyphotischen  Beckens,  Arch.  f.  Gynaek.,  vol.  xix,  p.  475. 


RARE   FORMS  OF   PELVIC  DISTORTION.  521 

gravity  of  the  prognosis  as  regards  the  mother  is  the  result  in  most 
instances,  not  so  much  of  the  mechanical  difficulties  of  delivery,  as  of 
her  feeble  vitality,  and  the  undeveloped  condition  of  her  heart  and  lungs. 
Again,  the  spinal  disease  may  be  reawakened  by  pregnancy,  and  in  child- 
bed may  lead  to  psoas  abscess,  and  other  suppurating  processes.  In 
many  cases  the  head  enters  the  pelvis  with  the  occiput  rotated  to  the 
rear.  Owing  to  its  smaller  size  the  forehead  is  better  adapted  for  en- 
gagement beneath  the  narrow  jjubic  arch  than  the  occiput,  but  perineal 
laceration  is  more  likely  to  occur,  as  the  uterine  force  in  fronto-anterior 
positions  is  directed  to  the  center  of  the  iDsrinasum. 

Treatment. — In  first  pregnancies  it  is  a  good  rule  to  await  the  end 
of  gestation,  as  experience  has  shown  that  Nature  may  accomplish  the 
delivery,  owing  to  the  mobility  of  the  pelvic  bones,  when  the  results  of 
the  pelvic  measurements  would  seem  to  indicate  this  to  be  impossible. 
Before  resorting  to  craniotomy,  a  careful  trial  should  be  made  in  head 
presentations  with  forceps.  After  the  head  has  entered  the  pelvis  the 
extraction  of  the  child  after  craniotomy  is  usually  not  difficult.  Witii 
the  head  movable  at  the  brim,  neither  craniotomy  nor  version  are  j)rac- 
ticable.  The  Caesarean  section  is  indicated.  If  the  kyphosis  is  extreme, 
so  that  the  ribs  overlap  the  ilia,  the  Porro  method  possesses  the  advantage 
of  furnishing  more  space  for  the  overcrowded  pelvic  and  abdominal 
viscera. 

III.    SCOLIO-KACHITIC    PeLVIS. 

A  brief  allusion  must  be  made  to  the  anatomical  characteristics  of 
a  purely  rachitic  pelvis,  in  order  to  render  the  differences  between  it 
and  a  scolio-rachitic  pelvis  intelligible.  The  leading  pathological 
features  of  the  infantile  rachitic  pelvis  consist  in  expansion  of  the  sub- 
pubic arch,  prominence  and  lowering  of  the  promontory,  widening  and 
elongation  of  the  sacrum,  flatness  of  the  venters  of  the  ilia,  between 
which  there  is  an  abnormally  wide  interval,  and  in  an  irregularly 
rounded,  triangular,  or  kidney-shaped  pelvic  inlet.*  These  anatomical 
features  are  not  altered  by  the  supervention  of  a  scoliosis,  but  the 
latter  adds  to  the  deformity  already  existing  its  own  pathological  char- 
acters. The  latter  combine  to  produce  a  marked  unilateral  asymmetry 
of  the  pelvis.f  The  most  ordinary  form  of  scoliosis  consists  in  a 
deviation  of  the  dorsal  vertebrae  to  the  right  and  a  comi^ensating  lumbar 
curve  to  the  left. 

The  adult  scolio-rachitic  pelvis  presents  many  points  of  resemblance 
to  the  infantile,  its  leading  peculiarities  being  the  following :  J  The 
entire  pelvis  is  inclined  toward  the  side  of  the  lumbar  curve,  and  rests 
chiefly  upon  the  corresponding  thigh.     The  cause  of  the  pelvic  asym- 

*  Fehling,  Arch.  f.  Gynaek,  Bd.  x,  1876,  p.  1 ;  Ihid.,  Bd.  xi,  lg77,  p.  173. 

f  Kehrer,  Arch.  f.  Gynaek.,  Bd.  v,  1873,  p.  GO. 

X  Leopold,  Das  ykoliotisches  und  kyphotisch-rachitischc?  Be(  ken,  Leipsic,  1879, 

p.  7. 


52^ 


THE  PATHOLOGY   OF  LABOR. 


metry  is  to  be  souglit  in  the  increased  weight  thus  thrown  upon  the  con- 
tracted half  of  the  pelvis  and  in  the  counter-pressure  exerted  upon  its 
articular  surface.  The  contracted  half  of  the  pelvis  is  higher  and 
more  inclined  than  its  fellow.  The  sacrum  has  sunk  deep  between 
the  ilia,  and  is  narrower  upon  the  side  of  the  lumbar  scoliosis.  The 
sacral  vertebral  bodies  are  sometimes  displaced  forward,  project- 
ing beyond  the  lateral  masses. 
The  promontory  is  displaced 
toward  the  contracted  side, 
and  the  corresponding  lateral 
mass  is  often  narrowed.  There 
is  rarely  anchylosis  of  the  hip- 
Joint.  The  ilium  is  erect,  looks 
inward,  and  is  narrowed  antero- 
posteriorly.  Its  crest  is  higher 
than  that  of  the  opposite  side. 
'I'he  symphysis  is  displaced 
toward  the  uncontracted  half 
of  the  pelvis.  The  ilio-pecti- 
neal  line  makes  a  sharp  curve 
inward  near  the  sacro-iliac  syn- 
chondrosis, and  then  pursues 
an  undulatory  course  to  tlio 
symphysis,  being  notably  bent 
inward  opposite  the  acetabu- 
lum. On  the  uncontracted  side 
the  corresponding  line  forms  a 
large  and  rounded  arch.  The 
tuber  iscliii  on  the  side  of  the  lumbar  scoliosis  is  turned  outward.  The 
oblique  diameter  of  this  side  is  greater,  but  the  distance  between  the 
sacrum  and  the  acetabulum  {distantia  sacro-cotyloidea)  is  much  shorter 
than  on  the  uncontracted  side.  The  plane  of  the  inlet  is  obliquely 
cordiform,  being  contracted  upon  the  side  of  the  lumbar  scoliosis  and 
expanded  on  the  other.  Exactly  the  reverse  conditions  obtain  at  the 
pelvic  outlet.*  The  conjugata  vera  is  notably  shortened  by  the  pro- 
truding promontory.  The  antero-posterior  diameter  of  the  outlet, 
although  contracted,  still  far  surpasses  the  conjugata  vera  in  lengtl.. 
Other  and  independent  pathological  conditions  may  aggravate  tlie 
obstruction  caused  by  the  peculiar  deformity  in  question.  Thus,  Hu- 
genberger  describes  a  case  of  scolio-rachitic  pelvis  complicated  by 
an  extensive  sacral  hydrorachis.f 

The   peculiar   deformity  of  a   scolio-rachitic   pelvis   obstructs   de- 
livery by  so  narrowing   the   space  between   the  acetabulum  and  the 

*  Leopold,  op.  cif.,  p.  10. 

f  HuGEXBERGER,  Arch.  f.  GytiiU'Ic.  B(l.  xiv,  p.  1. 


Fig.  315.— Specimen  of  scolio-rachitic  pelvis. 
(Litzmann.) 


RARE  FORMS  OF  PELVIC  DISTORTION. 


523 


sacrum  as  to  prevent  any  part  of  the  fetal  cranium  from  engaging  in 
it.  Rotation  is  thus  prevented,  and  the  delivery  must  be  accom- 
plished, if  indeed  it  be  possible,  by  the  same  mechanism  obtaining  in 
a  justo-minor  pelvis,  the  conjugata  vera  of  which  would  be  here  rep- 
resented by  the  distantia  sacro-cotyloidea,  and  the  transA-erse  diameter 
of  which  would  correspond  with  the  oblique  diameter  of  the  uncon- 
tracted  side. 


IV.  Robert's  Anchylosed  and  Traxsverselt  Contracted 

Pelvis. 

This  very  rare  form  of  contracted  pelvis  was  first  described  by 
Robert  in  1843.  Its  leading  characteristics  are  bilateral  sacro-iliac 
anchylosis  and  absence  or  rudimentary  development  of  the  sacral 
lateral  masses.  The  sacrum  is  consequently  very  narrow,  and  only 
slightly  wider  at  its  upper  than  at  its  lower  extremity.  The  longi- 
tudinal and  transverse  concavities  of  the  bone  are  nearly  or  quite  ob- 
literated. In  some  cases  the  normal  transverse  concavity  is  trans- 
formed into  a  convexity.  The  sacrum  is  deeply  pressed  between  the 
ossa   inuominata.     The   posterior  «. 

superior  iliac  spines  are  conse- 
quently closely  aj)proximated,  and 
the  ilia  project  far  above  the  base 
of  the  sacrum.  The  promontory 
encroaches  considerably  upon  the 
superior  strait.  The  iliac  venters 
are  flattened  and  directed  ante- 
riorly. The  linesB  ilio-pectinege 
are  slightly  or  not  at  all  curved, 
and  abnormally  approximated. 
The  descending  rami  of  the  pubes 
unite  at  an  acute  angle.  The 
ischiatic   spines   and   tuberosities 

are  in  close  proximity  to  each  other  and  to  the  lateral  margins  of  the 
sacrum.     The  dimensions  of  the  pelvis  are  materially  altered. 

The  transverse  diameter  is  notably  diminished  and  grows  shorter 
from  above  downward,  so  that  at  the  outlet,  in  marked  cases,  it  is  rep- 
resented by  a  mere  crevice  between  the  ischia  and  the  pubic  bones. 
The  form  of  the  inlet  is  that  of  a  long  and  narrow  wedge  with  its  apex 
directed  anteriorly.  The  average  diameter  of  the  outlet  is  less  than 
two  inches.*  The  antero-posterior  diameter  is  either  of  normal  length 
or  but  slightly  shortened,  since  the  projection  of  the  promontory  is 
compensated  for  by  the  absence  of  the  normal  outward  curve  of  the 
lateral  borders  of  the  inlet.     The  pelvic  canal  is  deeper  than  in  a  nor- 


FiG.  216.— Robert's  pelvis.    (Lambl.) 


*  Spiegelberg,  Lehrbuch,  p.  482. 


524 


THE  PATHOLOGY   OF   LABOR. 


mal  pelvis..  In  some  cases  there  is  asymmetry  of  the  two  lateral  halves 
of  the  pelvis. 

Etiology.— The  decisive  agency  in  the  production  of  the  deformity 
under  consideration  is  the  narrowness  of  the  sacrum,  which  is  chiefly 
due  to  the  diminished  breadth  of  its  lateral  masses,  but  also  in  a  cerr 
tain  measure  to  tlie  small  transverse  diameter  of  the  bodies  of  the 
sacral  vertebrae.  Diversities  of  opinion  prevail  regarding  the  connection 
between  the  narrowness  of  the  sacrum  and  the  sacro-iliac  synostosis. 

Some  authors  consider  deficient  development  of  the  centers  of  ossi- 
fication of  the  lateral  masses  as  the  primary  event,  and  the  anchylosis 
as  dependent  upon  this.  Others  regard  the  synostosis  as  tlie  primary 
change  which  determines  the  atrophy  of  the  lateral  masses,*  and  vari- 
ously refer  it  to  inflammatory  processes  or  to  arrested  development.! 
In  some  cases  it  would  seem  that  the  sacrum  Avas  originally  of  normal 
breadth,  but  was  narrowed  and  united  with  the  ilium  by  osteitis  and 
arthritis-!  The  transverse  convexity  of  the  anterior  sacral  surface  is 
explained  by  the  fact  tliat  the  bodies  of  the  vertebrse  are  pressed  for- 
ward by  the  weight  of  the  superimposed  trunk  after  the  union  of  the 
sacral  lateral  masses  with  the  ilia,  and  at  a  time  when  the  connections 
between  the  bodi(^  and  the  lateral  masses  are  still  pliable  and  yield- 
ing. The  close  approximation  of  the  ilia  and  their  parallel  course  are 
referable  to  the  narrowness  of  the  sacrum  and  to  increased  lateral 
pressure  upon  the  acetabula.*  The  combined  action  of  these  agencies 
produces  the  narrowness  of  the  subpubic  arch,  the  acutely  angular 
Junction  of  the  descending  pubic  rami,  the  approximation  of  the  iliac 
crests,  and  the  straight  course  of  the  lineae  ilio-pectinese. 

Diagnosis. — The  diagnosis  is  partly  based  upon  the  abnormal  ap- 
proximation of  the  posterior  superior  iliac  spines,  wliich  almost  cover 
the  deeply  seated  si)inous  process  of  the  last  liiml)ar  vertebra,  and  upon 
a  similar  approximation  of  the  trochanters,  of  the  tubera  ischii,  and  of 
the  iliac  spines  and  crests.  A  vaginal  examination  then  reveals  the 
parallel  course  of  the  descending  pubic  rami  and  the  striking  diminu- 
tion of  the  transverse  diameter.  The  differential  diagnosis  between 
the  Uobert  and  the  kyphotic  pelves  is  based  upon  the  absence  of 
a  kyphosis  in  the  former  and  upon  the  striking  difference  between  the 
respective  transverse  diameters. 

Prognosis. — This  is  bad  for  the  mother,  inasmuch  as  labor  is  com- 
pletely obstructed  by  the  deformity,  and  operative  interference  is 
always  necessary. 

The  Caesarean  section  is  indicated  in  the  interest  both  of  the  mother 
and  the  child. 

*  LiTZMANN,  Die  Formen  des  Beckens.  Berlin,  1861.  p.  62. 
t  Kehrer,  Monatsschr.  f.  Geburtsk..  Bd.  xxxiv.  18G9,  p.  20. 
t  IvLEixwACHTER.  Ai'ch.  f.  Gyiiaek.,  Bd.  i,  p.  156. 
^^  LiTZ.MAXx,  op.  cil.,  p.  65. 


RARE  FORMS  OF   PELVIC   DISTORTION.  525 

V.   Spondylolisthetic   Pelvis. 

This  rare  form  of  contracted  pelvis  was  first  described  by  Rokitansky 
in  1839.  Its  principal  pathological  feature  consists  in  the  separation  of 
the  last  lumbar  from  the  first  sacral  vertebra  and  in  the  descent  of  the 
body  into  the  pelvis,  where  the  inferior,  or  in  an  extreme  case  the  pos- 
terior, surface  of  the  body  of  the  last  lumbar  rests  upon  the  anterior  sur- 
face of  the  first  sacral  vertebra.  The  anterior  surface  of  the  last  lumbar 
vertebra  is  directed  downward.  The  anterior  surfaces  of  the  fourth, 
third,  and  second  lumbar  vertebrae  form  an  arch,  the  most  prominent 
part  of  which,  being  nearest  the  symphysis,  replaces  the  normal  promon- 
tory. The  result  of  this  displacement 
is  a  considerable  diminution  in  the 
antero-posterior  diameter  of  the  pelvic 
inlet.  The  descent  of  the  lumbar  por- 
tion of  the  spine,  which  is  gradually 
accomplished,  is  attended  by  atrophy 
of  the  intervertebral  cartilages,  and 
frequently  by  osseous  union  between 
the  bodies  of  the  lumbar  and  sacral 
vertebras.  The  weight  of  the  super- 
imposed trunk  being  now  transmitted 
to  the  anterior  surface  of  the  sacrum, 
instead  of  to  its  base,  the  pelvic  center  ^'«  ^ir.-spond^^oUsthetic  peu-is. 
of  gravity  is  displaced  forward.     This 

is  compensated  for  by  a  diminution  in  the  normal  pelvic  inclination, 
the  anterior  portion  of  the  pelvis  being  tilted  slightly  upward.  The 
pressure  upon  the  anterior  surface  of  the  sacrum  forces  its  base  back- 
ward. The  posterior  superior  iliac  spines  are  thus  widely  separated, 
and  the  apex  of  the  sacrum  is  thrown  forward,  encroaching  upon  the 
antero-posterior  diameter  of  the  outlet.  In  a  case  cited  by  Breslau,* 
the  sacro-iliac  synchondrosis  possessed  great  mobility. 

The  traction  upon  the  ilio-femoral  ligaments,  which  approximates 
the  tubera  ischii,  and  the  lateral  displacement  of  the  ilia,  due  to  re- 
cession of  the  sacrum,  produce  a  shortening  of  the  transverse  pelvic 
diameter,  which  becomes  more  marked  in  proportion  as  the  outlet  is 
approached. 

According  to  the  recent  investigations  of  N"eugebauer,f  the  spon- 
dylolisthetic pelvis  is  far  from  being  a  very  rare  anomaly.  Thus 
Neugebauer  has  succeeded  in  collecting  from  various  sources  twenty- 
three  anatomical  preparations  and  thirty  clinical  observations  made  on 
living  persons. 

*  Breslau,  Monatsschr.  f.  Geburtsk..  Bd.  xviii,  1861,  p.  411. 
t  Dr.  Franz  Ludwig  Neugebauer,  Arch.  f.  Gynaek.,  vol.  xix,  p.  441 ;  vol.  xx,  p. 
133;  vol.  xxii,  p.  347;  vol.  xxv,  p.  347. 


526 


THE  PATHOLOGY  OP  LABOR. 


Etiology.— Neugebauer,  who  has  studied  with  unwearied  patience 
and  zeal  the  anatomical  specimens  preserved  in  the  museums  of  Eu- 
rope, has  shown  that  in  true  spondylolisthesis  the  body  of  the  verte- 
bra alone  is  concerned  in  the  forward  displacement,  the  arch,  the  spine, 
and  the  transverse  processes  remaining  in  situ.  The  spinal  canal  un- 
dergoes, therefore,  an  antero-posterior  elongation,  and  the  cord  is  not 
subjected  to  pressure.  This  elongation  takes  place  at  the  junction  of 
the  arch  with  the  body.  It  does  not  appear  to  be  due  either  to  caries 
or  an  inflammatory  process.  The  original  cause  of  the  anomaly  Neuge- 
bauer  attributes  in  many  cases  to  a  congenital  separation  of  the  arch 
from  the  body  of  the  fifth  lumbar  vertebra,  due  to  defective  ossification, 
in  rare  instances  to  traumatic  fracture  of  the  sacral  articular  processes, 
and  in  some  cases  probably  to  fracture  of  the  arches  due  to  trauma- 
tism. The  latter  cause  he  admits,  however,  to  be  hypothetical,  as 
where  fractures  have  been  observed  it  is  not  possible  to  determine 
whether  they  occurred  primarily,  or  whether  they  resulted  secondarily 
from  the  strain  placed  upon  them  in  the  forward  and  downward  move- 
ments of  the  vertebral  body. 

In  a  few  instances  the  etiology  remains  unsolved.  The  deformity 
never  occurs  suddenly,  but  progresses  slowly  under  the  pressure  of  the 
trunk  until  the  gliding  movement  is  arrested  by  bony  union  between 
the  lumbar  and  sacral  vertebra.  Repeated  pregnancies  furnish  me- 
chanical conditions  favoring  the  spondylolsthesis,  though  pregnancy  is 
not  an  essential  element  in  the  causation,  as  the  accident  has  been  ob- 
served in  males. 

Diagnosis. — As  a  result  of  the  deformity,  the  abdomen  is  protuber- 
ant and  the  thorax  is  sunken  between  the  prominent  iliac  crests.  The 
trunk,  therefore,  appears  shortened,  while  the  extremities  are  relatively 
of  disproportionate  length ;  the  width  between  the  troclianters  is  in- 
creased ;  the  nates  are  flattened  and  pointed  below  with  deep  lateral 
depressions,  so  that  the  posterior  aspect  of  the  buttocks  possesses  a 
heart-shape  and  the  base  of  the  sacrum  and  the  posterior  superior 
spines  of  the  ilium  are  prominent.  Along  the  spine  a  deep  lumbo- 
dorsal  furrow  is  observable,  and,  owing  to  the  diminished  pelvic  incli- 
nation, the  external  genitals  are  directed  to  the  front.  The  gait  of 
patients  suffering  from  spondylolisthesis  is  peculiar.  The  steps  are 
short,  the  toes  are  but  slightly  turned  out,  and  the  footprints  follow 
one  another  in  nearly  a  straight  line.  It  is  not,  however,  easy  to  de- 
termine by  external  examination  alone  the  difference  between  spon- 
dylolisthesis and  a  deep-seated  lumbo-sacral  kyphosis.  The  internal 
examination  is  best  made,  according  to  Neugebauer,  in  the  upright  or 
lateral  position.  To  determine  the  existence  of  the  angle  formed  by 
the  projecting  lumbar  vertebra,  the  finger  should  be  introduced  along 
the  anterior  vaginal  wall  in  the  axis  of  the  superior  strait  directly  to 
the  spinal  column,  and  then  should  be  passed  downward  to  the  seat  of 


RAKE  FORMS  OP  PELVIC   DISTORTION.  527 

displacement,  carefully  feeling  in  the  descent  the  spinal  vertebrse  and 
the  extent  to  which  the  spine  covers  the  pelvic  brim. 

Olshausen  *  first  announced  the  fact  that  the  point  of  division  of 
the  abdominal  aorta  into  the  common  iliac  arteries  is  displaced  down- 
ward by  the  descending  lumbar  vertebras  to  such  an  extent  as  to  en- 
able the  palpating  finger,  introduced  into  Douglas's  cul-de-sac,  to  de- 
tect pulsation  in  these  vessels.  Hartmann  f  was  enabled  to  feel  the 
point  of  the  aorta's  division  on  the  upper  border  of  the  fourth  lumbar 
vertebra,  and  Breslau  J  felt  a  pulsating  vessel  in  the  same  situation. 
Neugebauer  states  that  this  displacement  is  not  pathognomonic,  but 
may  be  observed  in  other  instances  of  spinal  lordosis.  The  spondylo- 
listhetic lordosis  may  be  mistaken  for  the  sacral  deformity  peculiar  to 
a  rachitic  pelvis.  Breisky  **  suggests  that  this  error  may  be  avoided  by 
attention  to  the  fact  that  in  the  rachitic  pelvis  the  sacral  lateral  masses 
pass  outward  from  the  projecting  promontory,  while  in  spondylolisthe- 
sis one  can  feel  at  the  pelvic  inlet  only  the  rounded  prominence  of  a 
single  vertebral  body  without  laterally  expanding  wings.  The  pro- 
jecting angle  made  by  the  body  of  the  last  lumbar  vertebra  with 
the  anterior  surface  of  the  sacrum  is  also  easily  accessible  to  palpa- 
tion. 

Prognosis. — The  prognosis  in  cases  of  the  spondylolisthetic,  as  in 
other  forms  of  contracted  pelvis,  depends  upon  the  degree  of  the  ob- 
struction of  the  brim,  and  such  collateral  conditions  as  the  size  of  the 
child,  the  strength  of  the  pains,  and  the  position  of  the  head  at  the 
point  of  entry  into  the  pelvis.  Other  things  being  equal,  a  deviation 
of  the  spine  from  the  median  line  is  a  favorable  condition. 

Swedelin,!  from  a  careful  study  of  the  clinically  observed  cases, 
concludes : 

1.  That  where  the  false  conjugate  measures  above  3|  inches  no  dis- 
turbance of  labor  is  to  be  anticipated. 

2.  When  the  false  conjugate  measures  from  3  to  o^  inches,  preg- 
nancy may  be  permitted  to  proceed  to  term,  as  labor  at  term  may  be 
expected  to  terminate  favorably  for  both  mother  and  child,  without 
the  intervention  of  severe  operative  measures, 

3.  Labor  at  term,  with  a  false  conjugate  measuring  between  2^  to 
3  inches,  is  extremely  dangerous  for  the  child ;  the  prognosis  for  the . 
mother  is  likewise  bad. 

4.  With  less  than  2^  inches  in  the  false  conjugate,  extraction  of  the 
child  without  craniotomy  is  hardly  possible. 

*  Ohlshausen,  Monatsschr.  f.  Geburtsk.,  Bd.  xxiii,  p.  204. 

t  Hartmann,  Monatsschr.  f.  Geburtsk.,  Bd.  xxv,  18G5,  p.  469 ;  Bd.  xxxi,  1868,  p. 
285. 

X  Breslau,  Monatsschr.  f.  Geburtsk.,  Bd.  xviii,  p.  411. 

*  Breisky,  Ioc.  cif.,  p.  9. 

II  Swedelin,  Ein  neuor  Fall  von  klinisch  beobachteter  Spondylolisthesis,  Arch, 
f.  Gynaek,  vol.  xxii,  p.  250,  1880. 


528 


THE  PATHOLOGY  OP  LABOR. 


5.  In  multiparse  the  prognosis  is  the  more  serious  in  cases  where 
the  previous  labor  was  difficult. 
He  advises,  therefore : 

1.  Induction  of  premature  labor  at  the  thirty-second  week,  with  a 
false  conjugate  of  less  than  2f  inches. 

2.  Induction  of  premature  labor  at  the  thirty-second  week  Avith  a 
false  conjugate  measuring  between  2|  and  3i  inches. 

3.  Between  3^  and  d^  inches,  it  is  best  to  await  the  end  of  gesta- 
tion, unless  the  feeble  condition  of  the  patient  contra-indicates  a  wait- 
ing policy,  in  which  case  premature  labor  should  be  induced  in  the 
thirty-sixth  week. 

4.  Premature  labor  is  not  indicated  with  a  false  conjugate  exceed- 
ing 3^  inches. 

5.  If  the  end  of  gestation  has  been  reached  with  a  false  conjugate 
of  less  than  2f  inches,  wait  until  danger  threatens  the  patient,  and 
then  decide  between  craniotomy  and  the  Cassarean  section. 

6.  With  a  false  conjugate  of  less  than  2J  inches,  the  Caesarean  sec- 
tion is  called  for. 

VI.  Funnel-shaped  Pelvis. 

This  term  has  been  applied  to  two  varieties  of  deformed  pelves, 
both  of  which  are  exceedingly  rare.  The  inlet  of  the  first  variety  is 
either  normal  or  but  slightly  contracted  in  all  its  diameters,  but  its 
canal  is  gradually  and  progressively  narrowed  as  the  outlet  is  ap- 
proached. The  contraction  affects  chiefly  the  transverse  diameter ; 
but  either  this  alone,  the  antero-posterior  diameter  alone,  or  both  to- 
gether, may  be  shortened.  The  lateral  pelvic  Avails  converge  consider- 
ably, particularly  in  the  vicinity  of  the  outlet.  The  descending  rami 
of  the  pubic  bones  are  closely  approximated,  so  that  the  subpubic 
arch  forms  an  acute  angle.  The  spines  and  tuberosities  of  the  ischia 
are  in  close  apposition.*  The  sacrum  is  elongated  and  but  slightly 
curved,  its  position  resembling  that  of  the  sacrum  in  a  kyphotic  pelvis. 
It  will  be  seen  that  these  deformities  produce  a  close  resemblance  to 
the  typical  male  pelvis.  Pelves  of  this  variety  are  frequently  some- 
what unsymmetrical. 

The  second  variety  of  the  funnel-shaped  pelvis  is  so  exceedingly 
rare  as  to  require  only  a  passing  notice.  In  this  instance  the  deform- 
ity is  exactly  the  reverse  of  that  just  described,  the  inlet  being  very 
narrow  in  either  one  or  in  all  of  its  diameters,  wliile  the  outlet  is  of 
normal  size  or  even  abnormally  wide  in  one  or  more  directions.f 

Etiology. — The  causes  of  this  deformity  are  imperfectly  under- 
stood.    The  former  variety  is  believed  to  be  due  to  arrest  of  develop- 

*  PoppEL,  Monatsschr.  f.  Geburtsk.,  Bd.  xxviii,  18G6,  p.  234 ;  Braun,  Arcli.  f. 
Gynaek.,  Bd.  iii,  1870,  p.  154. 

t  Spiegelberg,  Lelirbuch,  p.  473. 


RARE  FORMS  OP   PELVIC  DISTORTION.  529 

ment  in  the  sacral  lateral  masses  and  to  other  causes  co-operating  to 
alter  the  direction  in  which  the  weight  of  the  trunk  is  normally  trans- 
mitted to  the  sacrum.  This  view  seems  to  be  confirmed  by  Schroeder's 
observation  that  the  funnel-shaped  pelvis  is  of  unusual  frequency  in  a 
certain  German  province,  where  the  children  are  carried  upon  the  back 
in  a  position  intermediate  between  the  erect  and  the  recumbent  pos- 
ture.* The  weight  of  the  body  would  in  this  case  be  transmitted  to 
the  sacrum  from  above  and  in  front,  as  in  the  kyphotic  pelvis,  rather 
than  from  behind  and  above,  as  is  the  case  in  a  natural  position,  and 
the  pelvis  would  neither  acquire  its  normal  anterior  curvature  nor  its 
posterior  inclination.  The  same  theory  explains  the  failure  of  the 
sacrum  to  exert  its  usual  wedge-like  action  in  separating  the  ossa  in- 
nominata,  and  accounts  for  the  consequent  approximation  of  the  tubera 
and  spines  of  the  opposite  ischia. 

Diagnosis. — In  cases  of  slight  deformity  the  diagnosis  is  difficult. 
In  well-marked  cases  the  approximation  of  the  ischial  tuberosities,  the 
slight  divergence  of  the  pubic  rami,  and  the  acute  subpubic  angle  are 
readily  appreciated.  Arrest  of  the  head  after  it  has  already  descended 
into  the  true  pelvis  will  often  be  the  first  circumstance  serving  to  di- 
rect the  attention  to  the  possible  existence  of  funnel-shaped  pelvis. 
Pelvic  menstruation,  with  particular  reference  to  the  distance  between 
the  spines  of  the  ischia  and  to  the  width  of  the  sacrum,  will  establish 
the  diagnosis. 

Prognosis. — In  the  slighter  grades  of  funnel-shaped  pelves,  the 
prognosis  is  not  grave.  If  the  deformity  be  marked,  however,  the 
child's  life  must  almost  invariably  be  sacrificed ;  and  gangrene  of  the 
maternal  soft  parts,  with  resulting  cicatrices  and  fistulas,  or  even  with 
caries  of  the  pubic  bones,  may  be  the  consequence  of  the  excessive 
pressure  to  which  these  tissues  are  liable.  In  a  case  reported  by  Schar- 
lau  the  lesions  already  mentioned  were  accompanied  by  perforation  of 
the  fundus  uteri  from  gangrene,  and  by  rupture  of  the  right  sacro-iliac 
artery. f 

The  treatment  consists  in  the  induction  of  premature  labor,  or,  at 
term,  in  a  cautious  attempt  to  deliver  with  forceps.  Should  moderate 
tractions  fail  to  advance  the  head,  perforation  and  extraction  with  che 
cranioclast  should  be  resorted  to. 

VII.  Pelves  deformed  by  Osteomalacia. 

Osteomalacia  is  almost  confined  to  females,  and  appears,  ordinarily, 
in  the  puerperal  state.  It  usually  attacks  fully  developed  bones,  but 
may,  rarely,  affect  them  during  their  period  of  growth.  It  is  gener- 
ally observed  in  multipara?,  although  primipara?  are  in  exceptional  cases 

*  ScHROEDER,  Lehrbiich,  p.  582. 

f  ScHARLAU,  Monatsbchr.  f.  Geburtsk.,  Bd.  xxvii,  1866,  p.  1. 
34 


530 


THE  PATHOLOGY  OF  LABOR. 


Fig.  218.— Osteomalacia.    (Specimen 
from  Woofl's  Museum.) 


its  victims.  Each  succeeding  pregnancy  is  usually  attended  by  a  pro- 
gressive development  of  the  disease,  which  may,  however,  become  non- 
progressive, or  even  be  completely  and  permanently  arrested.*  In  a 
case  of  this  kind  the  bone  is  restored  to  its  normal  histological  state,  al- 
though its  deformity  remains.  Osteomalacia  may  involve  the  entire 
osseous  system,  or  be  confined  to  individual  bones.     In  the  latter  case 

the  long  bones  and  the  vertebras 
are  most  frequently  diseased,  f  In 
puerperal  osteomalacia  the  pelvis 
and  the  vertebra?  are  predominantly 
and  often  exclusively  affected.  The 
disease  is  regarded  as  an  osteomye- 
litis, which,  beginning  in  the  center 
of  bones,  advances  toward  their  pe- 
riphery. The  essential  pathological 
process  consists  in  the  absorption 
of  calcareous  matter,  through  the 
Haversian  canals,  and  in  the  sub- 
stitution of  hypertrophic  medullary 
tissue  for  the  softened  osseous  struct- 
ures. The  natural  result  of  the 
changes  is  great  friability  or  pli- 
ability of  the  bones,  according  to 
the  stage  reached  by  the  disease,  and  their  consequent  distortion  by 
compression  or  traction.  The  bones  are  of  very  light  weight.  Their 
transverse  section  reveals  a  porous,  diploe-like  structure.  Their  outer, 
hard  lamella  is  exceedingly  thin,  or  entirely  absent.  The  bones  are 
of  a  wax-like  softness,  being  readily  cut  and  molded.  The  term  rub- 
ber or  elastic  pelvis  has  been  applied  to  those  pelves  whose  bones 
have  reached  this  stage  of  degeneration.  In  the  most  advanced  cases 
the  osseous  tissue  is  represented  merely  by  membranous  sacs  of  peri- 
osteum inclosing  medullary  tissue  and  fat. 

Morbid  Anatomy. — The  osteomalacic  pelvis  presents  the  following 
pathological  anatomical  features :  The  sacral  lateral  masses  are  very 
narrow,  and  the  entire  bone,  which  is  displaced  downward  between  the 
ilia,  is  sharply  curved.  The  promontory  is  accordingly  deeply  do- 
pressed  and  approximated  to  the  symphysis  as  well  as  to  the  apex  of 
the  sacrum,  which  is  itself  displaced  forward  and  curved  upward.  The 
promontory  and  the  apex  of  the  sacrum  may,  in  marked  cases,  almost 
touch  each  other.  The  ilia  are  placed  almost  vertically.  Their  crests 
are  elongated  and  sharply  curved.  The  anterior  superior  spinous  pro- 
cesses are  approximated.  The  posterior  superior  spinous  processes  are 
in  the  same  plane  with  the  posterior  surface  of  the  last  lumbar  spinous 

*  WiNCKEL,  Monatsschr.  f.  Geburtsk.,  Bd.  xxiii,  1864,  p.  321. 
f  LiTZMANN,  Die  Formen  des  Beckens,  Berlin,  1861. 


RARE  FORMS  OF  PELVIC  DISTORTION.  53I 

process.  The  iliac  fossa  is  divided,  near  its  middle,  by  a  vertical  fur- 
row, which  may  be  bifurcated  at  its  lower  end.  A  prominence  corre- 
sponding to  either  acetabulum  encroaches  more  or  less  upon  the  pelvic 
canal.  In  grave  cases  these  prominences  may  even  come  in  contact 
with  the  promontory.  The  pubic  bones  are  in  close  apposition,  and 
the  pelvic  inlet  is  consequently  pointed  anteriorly,  while  the  symphysis 
is  prominent  and  sharply  angular.  The  ascending  rami  of  the  ischia 
and  the  descending  rami  of  the  pubes  are  apj)roximated,  and  the  sub- 
pubic arch  is  partly  or  completely  abolished.  The  tuberosities  of  the 
ischia  are  approximated.  The  deformities  described  may  be  asym- 
metrical. The  pelvic  canal  is  greatly  narrowed,  the  outlet  usually 
suffering  more  distortion  than  the  inlet.  The  pelvic  inlet  and  canal 
are  of  triangular  form,  and  assume,  in  the  highest  grades  of  the  dis- 
ease, the  shape  of  the  letter  Y.  The  transverse  diameter  is  always 
contracted,  and  its  shortening  is  more  marked  as  the  outlet  is  ap- 
proached. The  approximation  of  the  ischial  tuberosities  and  of  the 
pubic  bones,  together  with  the  anterior  displacement  of  the  apex  of  the 
sacrum,  sometimes  ahnost  obliterates  the  outlet. 

Etiology. — The  etiology  of  this  pelvic  deformity  may  be  divided 
into — 1.  That  of  the  original  disease ;  and,  2.  That  of  the  resulting 
distortions.  1.  The  causes  of  osteomalacia  are  obscure.  Cold  and 
damp  dwellings,  insufficient  air  and  light,  inadequate  aliment,  and  ex- 
posure are  cited  as  exciting  causes ;  *  but  it  seems  probable  that  these 
alone  are  insufficient  etiological  agencies  unless  some  undetermined 
predisposing  cause  be  already  in  operation.  The  disease  is  sometimes 
observed  to  assume  an  endemic  form,  particularly  in  countries  where 
the  above-mentioned  exciting  causes  prevail,  as,  for  instance,  in  the 
Rhine  provinces  and  in  some  parts  of  Italy.  In  the  United  States  it 
is  only  observed  in  isolated  cases,  usually  in  persons  of  foreign  birth. 
2.  The  immediate  causes  of  the  distortions  are  found  (a)  in  the  altered 
structure  of  the  bones,  and  (b)  in  the  various  forces  acting  mechani- 
cally upon  them,  (a)  The  lime-salts,  which  impart  stability  to  normal 
bones,  are  greatly  diminished.  Although  it  is  not  definitely  known 
by  what  emunctories  they  are  removed,  it  is  probable  that  they  are 
chiefly  excreted  by  the  kidneys.  Gusserow  states  that  the  proportion 
of  lime-salts  in  the  milk  of  women  suffering  from  osteomalacia  is  ab- 
normally large.f  Pagenstecher  opposes  this  view.J  (b)  Tlie  distor- 
tions are  chiefly  produced,  when  once  softening  of  the  bones  has  oc- 
curred, by  the  muscular  traction  and  by  the  pressure  exerted  upon  the 
pelvic  walls.  This  pressure  will  vary  in  direction  and  intensity  with 
the  different  positions  assumed  by  the  patient.  If  the  dorsal  decubitis 
be  long  maintained,  the  sacrum  is  displaced  forward  and  the  ilia  are 

*  Hennio,  Arch.  f.  Gynaek.,  Bd.  v,  1873,  p.  519  ef  seq. 

t  Gusserow,  Monatsschr.  f.  Geburtsk.,  Bd.  xx.  1803,  p.  19. 

}  Pagenstecher,  Monatsschr.  f.  Geburtsk.,  xix,  1SG2,  p.  128. 


632 


THE  PATHOLOGY  OF  LABOR. 


folded  upon  themselves,  so  that  a  vertical  furrow  traverses  the  iliac 
fossae.  In  the  erect  position  the  sacrum  is  forced  downward  and  for- 
ward, dragging  with  it  the  posterior  parts  of  the  ilia,  and  increasing 
the  bend  in  the  iliac  fossa.  The  same  effect  is  produced  by  the  upward 
and  backward  pressure  exerted  upon  the  acetabula  by  the  femoral 
heads.  In  the  lateral  position  the  ilia  are  forced  inward,  and  the 
transverse  pelvic  diameter  is  thus  diminished.  In  the  sitting  posture 
the  apex  of  the  sacrum  and  the  tubera  ischii  are  forced  upward.  The 
deviations  referred  to  above  result  from  excess  of  pressure  in  some 
given  direction,  or  from  unequal  jn-ogress  of  the  disease  in  the  various 
bones. 

Diagnosis. — In  the  earlier  stages  the  history  of  violent  pains  in  the 
pelvis  and  lower  extremities  will  direct  attention  to  the  existence  of 
osteomalacia,  and  careful  mensuration  will  reveal  beginning  distortion. 
Pelvimetry  is  most  satisfactorily  performed  during  anaesthesia,  which 
permits  the  introduction  of  the  entire  hand  within  the  pelvis.  If  the 
disease  be  more  advanced  the  diagnosis  will  be  based  upon  the  above- 
mentioned  morbid  anatomical  features,  chief  among  which  are  the 
prominent  pointed  symphysis,  the  parallel  pubic  rami,  the  approxima- 
tion of  the  tubera  ischii,  the  accessibility  of  tlie  i)romontory  to  palpa- 
tion, the  curvature  of  the  sacrum,  and  the  folding  of  the  ilia.  8pie- 
gelberg  insists  on  the  value  of  the  pliability  of  the  pelvic  bones  as  an 
aid  to  diagnosis.*  The  pliability,  although  slight  during  pregnancy, 
is  more  marked  in  labor.  Its  first  sign  is  great  sensitiveness  to  jiress- 
ure  over  tlie  symphysis.!  Its  grade  can  be  decermincd  by  the  method 
recommended  for  pelvic  measurements. 

Prognosis. — The  prognosis  for  the  mother  is  very  bad.  The  ma- 
jority of  patients  succumb  to  the  effects  of  pressure  in  labor,  to  the 
results  of  operative  interference,  or  to  the  exhaustion  attending  the 
almost  invariably  progressive  disease.  Amelioration  of  the  symptoms 
and  signs  sometimes  occurs  when  conception  does  not  recur.  In  very 
exceptional  cases  not  only  may  the  pathological  process  be  arrested 
but  the  normal  histological  character  of  the  bone  restored,  (a)  Even 
in  such  cases,  however,  the  pelvic  deformity  remains  unaltered,  and 
would  sadly  cloud  the  prognosis  if  conception  should  recur.  The 
prognosis  for  the  child  is  more  favorable.  In  the  beginning  of  the 
disease,  and  in  cases  of  pliable  pelvis,  the  child  maybe  born  uninjured.  J 
In  more  advanced  cases  a  fair  prospect  of  preserving  its  life  is  afforded 
by  a  resort  to  the  Cesarean  section. 

The  treatment  will  depend  upon  the  results  of  a  careful  exploration 

*  Spiegelbercj,  Lehrbuch,  p.  480. 

t  WiKCKEL,  Monatsschr.  f.  Geburtsk.  Brl.  xxiii,  18G4,  p.  81. 

X  Kezmarszky,  Arch.  f.  Gynaek.,  Bd.  iv,  1872,  p.  537 ;  Fasbexder  and  Plxlex, 
Monatsschr.  f.  Geburtsk.,  Bd.  xxxiii,  18G9,  p.  177;  Breslau,  Jbid,  Bd.  xx,  18(52,  p. 
353;  ScHiECK,  Jbid.,  Bd.  xxvii,  1863,  p.  178;  Winckel.,  iitrf.,  Bd.  xxiii,  18G4,  p.  81. 


RARE  FORMS  OF   PELVIC   DISTORTION. 


>33 


of  the  pelvic  space.  This  should  determine,  first,  whether  it  is  possi- 
ble to  extract  a  living  child  through  the  natural  passages ;  or,  second, 
where  that  is  out  of  tlie  question,  whether  it  is  possible  to  deliver  after 
craniotomy.  In  estimating  the  chances  it  will  be  necessary  to  take 
into  consideration  the  pliability  of  the  pelvis,  it  having  been  found 
possible  in  many  case§  of  advanced  softening  to  open  up  the  pelvic 
canal  with  the  hand  and  deliver  by  version.  Lazzati  and  Casati,  in 
Milan,  found  it  was  only  necessary  to  perform  Ctesarean  section  twice 
in  sixty-two  cases.  Litzmann  in  1857  reported  forty  Cajsarean  sec- 
tions in  eighty-five  cases;  fifteen  years  later  Hugenberger  reported 
but  four  Csesarean  sections  in  twenty-five  cases  (Spiegelberg).  Lately 
Porro's  operation  has  been  proposed  by  Levy  in  osteomalacia  as  a  cura- 
tive measure  ;  but  of  this  further  experience  is  necessary. 

Pseudo-Osteomalacia. — It  is  possible  for  a  rachitic  pelvis,  in  which 
the  rachitic  changes  are  excessive,  to  present  a  shape  similar  to  that  in 
osteomalacia.  This  form  is,  however,  distinguishable  from  the  latter 
through  the  hardness  of  the  bones,  their  smaller  size,  the  greater  dis- 
tance between  the  anterior  superior  spinous  processes,  and  the  traces 
of  rickets  in  other  parts  of  the  skeleton. 

VIII.   Pelves   deformed  by  Exostosis,  or  by  Osseous  Tumors. 

Fractures  of  the  pelvic  bones  may  be  the  source  of  pelvic  deform- 
ity, either  by  producing  permanent  displacement  of  the  bones,  or  by 
leading   to  such  extensive  deposits  of 
callus    as    to   obstruct    the    parturient 
canal. 

Multiple  exostoses  of  the  pelvic 
bones  are  of  comparatively  frequent  oc- 
currence, and  are  usually  attended  by 
multiple  exostoses  of  the  entire  osseous 
framework.*  The  pelves  in  which  they 
are  foiind  are,  as  a  rule,  either  of  the 
oblique-ovate  or  of  the  rachitic  variety, 
and  the  combination  of  these  deform- 
ities is  naturally  a  serious  one,  since 
the  maternal  soft  parts  are  liable  to  con- 
tusion and  perforation  at  many  points 
during  parturition.  The  ilio-pectineal 
eminence  is  sometimes  so  unusually 
prominent  and  sharp  as  to  offer  an 
obstacle  to  parturition.      The  same  is 

true  of  the  pubic  crest  and  spine.  Osteo-fibromata,  sarcomata,  en- 
chondromata,  and  carcinomata  connected  with  the  pelvic  bones  con- 

*  Leopold,  Arch.  f.  Gynaek.,  Bd.  iv,  1873,  p.  336  ;  Kormann,  Ibid.,  Bd.  vi,  1874, 
p.  473. 


219.— Osseous  tumors  filling  pelvic 
cavity.    (Naegele.) 


534  THE  PATHOLOGY  OF  LABOR 

stitute  tumors  of  rare  occurrence.  They  usually  spring  from  the 
sacrum  or  from  the  symphysis,*  and  are  of  various  dimensions. 
Some  of  them  almost  completely  conclude  the  parturient  canal,  and 
may  constitute  formidable  obstructions  to  delivery. 

In  this  connection  may  be  mentioned  as  of  rare  occurrence  anch}-- 
losis  of  the  coccyx,  a  condition  which  materially  shortens  the  antero- 
posterior diameter  of  the  outlet. 

IX.  Absence  of  the  Symphysis. 

In  this  variety  of  deformed  pelvis  the  symphysis  is  congenitally 
absent,  and  is  replaced  either  by  strong  fibrous  bands  extending  be- 
tween the  opposing  surfaces  of  the  pubic  bones,  or  by  the  muscles  and 
connective  tissue  of  the  perinaeum.  It  is  accordingly  designated  by 
Litzmann  the  split  pelvis,  f 

Morbid  Anatomy. — It  is  usually  attended  by  ectopia  vesicae  and  by 
hiatus  of  the  abdominal  wall  in  the  linea  alba.  In  rare  cases  an  ab- 
dominal hiatus  exists  without  a  corresponding  opening  in  the  bladder. 
If  the  split  be  located  immediately  below  the  symjjhysis,  the  urethrals 
involved  rather  than  the  bladder,  and  is  sometimes  so  defective  that 
cystocele  may  occur  through  the  abnormal  opening  in  its  anterior  wall.  J 
Both  the  external  and  internal  organs  of  generation  are  imjjorfectly 
developed.  If  the  anterior  wall  of  the  urethral  canal  be  absent,  the 
mucous  membrane  of  the  fundus  vesicae  is  directly  continuous  with 
that  of  the  vaginal  orifice.  In  other  cases  the  bladder  is  only  sepa- 
rated from  the  vulva  by  a  narrow  bridge.  Tlie  vulva  and  anus  are 
often  situated  more  anteriorly  than  normal,  and  the  perinaeum  is  thus 
diminished  in  thickness.  The  clitoris  is  bifurcated  or  absent,  the 
nymphfe  are  imperfectly  developed,  and  the  defective  labia  majora 
widely  separated.  The  vagina  may  be  imperforate  or  partially  oc- 
cluded by  a  transverse  septum.  The  uterus  may  be  double  and  the 
ovaries  rudimentary.*  In  a  case  reported  by  "Winkler,  separation  of 
the  pubic  bones  had  occurred  at  the  symphysis,  as  the  result  of  an 
accident  in  early  life,  and  they  were  only  connected  by  bands  of  fibrous 
tissue.!  The  sacrum  of  a  split  pelvis  is  displaced  forward  between  the 
ilia,  its  vertical  and  transverse  curvature  diminished,  and  its  length 
increased.  The  iliac  fossfe  are  widely  separated.  The  entire  pelvis 
is  greatly  flattened  antero-posteriorly,  and  strongly  resembles  the 
rachitic  pelvis. 

Etiology. — The  cause  of   the  existing  deformity  is  found  in  the 

*  Harris,  Am.  Jour,  of  Obstet.,  vol.  iv,  1872.  pp.  633,  645 ;  Braun,  Monatsschr 
f.  Gebuitsk.,  Bd.  xxi,  1863,  p.  311. 

t  Litzmann,  Die  Formen  dcs  Beckons.  Berlin.  1861. 

t  Kleinwachter,  Monatssclu-.  f.  Gebiirtsk.,  Bd.  xxxiv,  1869,  pp.81  el seq. 

*  LiTZMAX.v,  Arch.  f.  Gynack.,  B  1  iv.  1872.  p.  272. 
II  Winkler,  Arch.  f.  Gynaek.,  Bd.  i,  1870,  p.  346. 


ABNORMALITIES  OF  THE  SEXUAL   ORGANS.  535 

inurejiised  pressure  to  which  the  lateral  pelvic  walls  are  subjected  owing 
to  the  absence  of  the  symphysis.  The  natural  resistance  to  the  sepa- 
ration of  the  lateral  pelvic  parietes  offered  by  the  normal  symphysis 
being  wanting,  the  weight  of  the  superimposed  trunk  naturally  forces 
them  apart  posteriorly,  while  the  pressure  of  the  femora  bends  them 
inward  anteriorly.  In  some  instances  anchylosis  of  the  sacro-iliac 
joints  occurs,  as  a  consequence  of  an  arthritis  resulting  from  the  in- 
creased pressure  thrown  upon  them  by  the  lateral  displacement  of  the 
ossa  innominata.*  In  other  cases  sacro-iliac  synostosis  is  not  present, 
but  the  firmness  of  the  pelvis  is,  nevertheless,  such  as  to  admit  of  un- 
impeded locomotion. 


CHAPTER  XXVIII. 

ABNORMALITIES  OF   THE  SEXUAL   ORGANS. 

Atresia  of  the  genital  canal. — Vulvar  atresia. — Vaginal  atresia. — Cystoeele. — Recto- 
cele. — Retention  of  urine. — Impacted  calculi. — Vaginal  hernias. — Cystic  degen- 
eration of  the  vaginal  wall. — Vaginismus. — Echinococci. — Uterine  atresia. — 
Conglutinatio  orificii  externi. — Cicatrical  atresia. — Rigidity. — Thrombus  of  the 
cervix. — Symptoms  of  atresia. — Note  on  treatment. — Tumors, — Fibroids. — Can- 
cer.— Ovarian  tumors. 

Atresia  of  the  Genital  Canal.  Obstruction  of  the  Gen- 
erative Passages  by  Morbid  Processes  in  Neighboring 
Tissues. 

I.  Vulvar  Atresia. — The  term  atresia.,  as  here  employed,  implies 
either  partial  or  complete  obstruction  of  the  genital  canal. 

Atresia  of  the  hymen  is  of  more  frequent  occurrence '  than  any 
other  variety  of  vulvar  stenosis. f  Unless  unusually  thick  and  rigid, 
however,  the  atresia  offers  only  a  trifling  obstruction  to  delivery.  Its 
chief  importance  is  owing  to  the  fact  that  it  leads,  in  the  unimpreg- 
nated  state,  to  retention  and  accumulation  of  the  menstrual  fluid,  which 
may  occasion  serious  inflammatory,  septic,  or  reflex  nervous  phenomena. 
Adhesions  of  the  labia  majora  and  minora  constitute  other  forms  of 
incomplete  vulvar  atresia.  Their  causes  are  often  ulcerative  processes 
resulting  from  injuries,  or  developed  during  the  course  of  variola  and 
other  constitutional  diseases.  Under  these  circumstances  they  may 
consist  of  unyielding  cicatricial  tissue,  which  either  ruptures  in  labor, 
or,  forcing  the  head  backward,  leads  indirectly  to  the  exertion  of 
injurious  pressure  upon  the  recto-vaginal  septum  or  upon  the  peri- 

*  Freund,  Arch.  f.  Gynaek.,  Bd.  iii.  1872.  pp.  398,  406. 

f  Jexks,  Atresia  of  the  Generative  Passages  of  Women,  Chicago  Med.  Jour,  and 
Examiner,  September,  1880,  p.  4. 


536 


THE  PATHOLOGY   OP   LABOR. 


ngeum.  If  the  atresia  be  congenital,  and  not  the  result  of  cicatricial 
changes,  it  will  rarely  constitute  an  impediment  to  parturition.  When 
the  entrance  to  the  vagina  is  very  narrow,  without  exhibiting  any 
pathological  condition,  as  is  often  the  case  with  aged  primipar*,  it 
may  be  extensively  lacerated  in  labor.  A  rigid  perinaeum  is  also  well 
known  to  constitute  a  serious  impediment  to  the  normal  progress  of 
parturition.  (Edema  of  the  vulva,  usually  attendant  upon  albumi- 
nuria, produces  atresia,  and  the  oedematous  labia  and  perinaeum  may 
become  gangrenous  from  excessive  pressure  during  labor.  Vulvar 
hsematoma,  or  thrombus,  if  formed,  as  it  rarely  is,  before  delivery, 
likewise  obstructs  the  outlet  of  the  parturient  canal.  A  similar  effect 
is  produced  by  cancers  and  polypi  of  the  vulva,  which  are,  however, 
not  often  of  sufficient  size  to  occasion  serious  difficulty. 

II.  Vaginal  Atresia. — This  variety  of  stenosis  of  the  generative 
passages  is  either  congenital  or  accidental,  complete  or  incomplete. 

(a)  The  congenital  form  may  be  either  incomplete,  in  which  case 
the  stenosis  sometimes  affects  the  entire  length  of  the  vagina,  and 
sometimes  forms  a  circumscribed  ring-like  stricture,*  or  it  may  be  com- 
plete. In  either  case  the  atresia  is  due  to  arrested  embryonic  develop- 
ment, which,  in  the  latter  instance,  must  have  originated  at  a  very  early 
period  of  fetal  life.  Congenital  narrowing  of  the  vagina  independent 
of  any  morbid  process  or  any  arrest  of  development  is  often  observed, 
but  is  of  trifling  consequence,  being  overcome  by  the  hypertrophy  and 
relaxation  accompanying  pregnancy,  and  by  the  natural  expulsive 
forces.  Absence  of  the  vaginal  canal  does  not  necessarily  imply  ab- 
sence or  imperfect  development  of  the  uterus.  Fallopian  tubes,  or 
ovaries. 

(b)  Accidental  vaginal  atresia  may  be  either  complete  or  partial, 
but  is  ordinarily  of  the  latter  form.  Both  varieties  result  from  the 
cicatrization  following  superficial  or  deep  ulceration  produced  by  con- 
stitutional diseases  or  by  local  injury.  The  diseases  during  the  course 
of  which  vaginal  ulceration  occurs  are  chiefly  diphtheria,  variola,  ty- 
phoid fever,  cholera  Asiatica,  and  syphilis.  The  mechanical  injuries 
productive  of  vaginal  stenosis  are  mainly  those  incident  to  protracted 
labors,  to  the  unskillful  employment  of  instruments,  or  to  the  improper 
performance  of  obstetrical  operations ;  but  caustic  local  applications, 
pessaries,  excessive  coition,  or  any  local  irritant  of  sufficient  intensity 
to  produce  ulceration,  may  lead  to  the  same  result.  In  consequence 
of  impaired  vitality,  ulceration  and  stenosis  of  the  vagina  may  follow 
normal  labors  unattended  by  any  injurious  pressure.  Complete  acci- 
dental vaginal  atresias  are  produced,  as  a  rule,  by  grave  mechanical 
injuries,  but  may  also  follow  the  acute  infectious  diseases  enumerated 
above,  although  the  ulcerations  attending  the  latter  usually  lead  to  only 
partial  stenosis. 

*  ScHROEDER,  Lehrljuch,  Gte  Aufl.,  p.  491. 


ABNORMALITIES   OP   THE  SEXUAL   ORGANS.  537 

Mention  may  properly  be  made,  in  this  connection,  of  various  mor- 
bid conditions  involving  tissue  adjoining  the  vagina  and  resulting  in 
diminution  of  its  caliber. 

Simple  prolapse  of  the  anterior  vaginal  wall  sometimes  occurs,* 
and,  assuming  an  oedematous  condition  owing  to  the  obstruction  of  its 
circulation,  decidedl}-  constricts  the  parturient  canal.  Cystocele  fre- 
quently accompanies  the  prolapse  of  the  anterior  vaginal  wall.  If  the 
bladder  be  distended  with  urine,  the  cystocele  presents  a  tense  fluctu- 
ating tumor  of  sufficient  size  to  completely  occlude  the  vagina.  The 
subjective  symptoms  of  this  condition  are  intense  pain  with  vesical 
tenesmus  and  dysuria.  In  some  cases  the  cystocele  is  retracted  by  the 
longitudinal  cervical  contractions,  or  it  may  be  forced  still  farther 
downward  by  the  advancing  foetus,  producing  obstructed  labor  and 
even  ruptute  of  the  vesico-vaginal  septum. 

Prolapse  of  the  posterior  vaginal  wall  with  rectocele  produces 
vaginal  stenosis,  especially  if  the  rectum  be  filled  with  impacted  feeces. 
This  condition  is  easily  recognized  by  the  characteristic  feeling  of  the 
fecal  mass,  which  admits  of  indentation  by  the  palpating  finger. 

Retention  of  urine  becomes  oftentimes  a  grave  complication  of 
parturition,  in  that  the  distended  bladder,  by  displacing  the  uterine 
axis,  prevents  the  jjresenting  part  from  engaging  in  the  superior  strait. 
The  pressure  it  exerts  upon  the  uterus  also  interferes  with  the  efficient 
contraction  of  that  organ.  The  diagnosis  is  based  upon  the  presence 
of  a  tumor  near  the  uterus,  and  often  situated  laterally  from  it,  which 
disappears  as  the  urine  is  withdrawn  through  a  catheter.  The  intro- 
duction of  the  latter  is  often  extremely  difficult,  owing  to  the  com- 
pression of  the  urethra  and  the  retraction  of  the  meatus  urinarius 
within  the  vagina. 

Vesical  calculi,  if  of  any  considerable  magnitude,  seriously  obstruct 
the  caliber  of  the  vagina  by  becoming  impacted  in  the  base  of  the 
bladder,  the  urethra,  or  a  cystocele,  between  the  foetus  and  the  pelvic 
walls.  Under  these  circumstances  not  only  is  the  labor  obstructed, 
but  contusion  and  rupture  of  the  soft  parts,  resulting  in  vesico-vaginal 
fistula,  may  ensue. 

Impacted  calculi  have  sometimes  been  mistaken  for  exostoses ;  f 
but  attention  to  the  fact  that  they  are  immovable  during  the  pains 
and  movable  in  the  intervals,  together  Avith  the  use  of  the  vesical 
sound,  will  prevent  this  error. 

Vaginal  hernia  consists  of  a  sac  formed  by  the  protrusion  of  the 
vaginal  wall,  lined  with  the  parietal  peritonaeum  and  containing  some 
of  the  abdominal  or  pelvic  viscera.  The  organs  usually  present  in  the 
sac  are  coils  of  the  small  and  large  intestine,  the  middle  portion  of 
the   rectum  with  its  elongated   meso-rectum,  parts  of  the  omentum, 

*  Benicke,  Ztschr.  f.  Geburtsh.  u.  Gynaek.,  Bd.  ii,  Heft  2,  1878,  p.  250. 
•f  ScHROEDER,  Lohrbuch,  Ote  Aufl.,  p.  500. 


538 


THE  PATHOLOGY   OF  LABOR. 


portions  of  the  urinary  bladder,  and  sometimes  blood,  Avitli  various 
products  of  peritoneal  inflammation.  The  location  of  the  hernia  is 
usually  in  the  posterior  vaginal  wall,  although  it  may  insinuate  itself 
between  the  uterus  and  the  bladder,  and,  descending,  produce  hernia 
of  the  labia  majora.  Perineal  hernias  are  formed  by  hernial  sacs 
which  pass  behind  the  ligamentum  latum  and  distend  the  jaerinaeum. 
The  intestinal  vaginal  hernia  is  the  most  important  variety,  inasmuch 
as  it  may  not  only  obstruct  labor,  but  may  itself  become  incarcerated 
or  strangulated,  thus  leading  to  symptoms  of  the  gravest  import. 
The  diagnosis,  which  can  be  rendered  very  probable  by  palpation  per 
vaginam,  is  made  certain  by  a  rectal  examination. 

Vaginal  neoplasmata,  the  most  important  of  which  are  carcinomata 
and  fibromata,  are  rare  sources  of  vaginal  stenosis,  as  is  likewise 
thrombus  of  the  vagina.  Slight  obstruction  to  labor  may  result  from 
a  pathological  condition  of  the  vaginal  mucous  membrane  described 
by  Winckel,*  under  the  title  colpohyperplasia  cystica,  and  consisting  of 
the  development  in  the  mucous  membrane  of  numerous  small  and 
closely  aggregated  flattened  cysts.  The  cysts  are  believed  to  be  pro- 
duced by  the  distention  of  glandular  depressions  in  the  mucous 
membrane  with  mucus,  which,  according  to  Zweifel,f  eventually  pro- 
duces trimethylamine  gas  by  decomposition.  Others  consider  the  loca- 
tion of  the  gas  to  be  in  the  interstices  of  the  submucous  connective 
tissue.  J 

Vaginismus  is  rarely  a  cause  of  vaginal  stenosis  in  labor,  inas- 
much as  it  is  itself  a  cause  of  sterility.  It  has,  however,  been  found 
in  certain  instances  to  constitute  so  serious  an  obstacle  to  delivery  as 
to  necessitate  operative  interference.  In  a  recent  instance  in  my  own 
practice  the  spasmodic  contraction  of  an  unusually  developed  levator- 
ani  muscle — -a  spasm  which  was  uncontrolled  by  complete  chloroform 
anassthesia — rendered  forceps  necessary.  After  prolonged  effort  extrac- 
tion was  accomplished,  but  the  head  was  enormously  elongated.  The 
child  died  of  tetanus  a  few  days  after  birth.  In  double  vagina  tlie 
septum  is  sometimes  a  source  of  slight  vaginal  atresia. 

Intrapelvic  echinococci  constitute  a  rare  cause  of  vaginal  constric- 
tion. Wiener  *  collected  seven  cases  of  pelvic  echinococci,  most  of 
which  occupied  the  loose  connective  tissue  between  the  vagina  and 
rectum.  The  leading  symptoms  due  to  their  presence  during  preg- 
nancy were  deep-seated  traction  in  the  pelvis,  severe  pain,  vesical 
tenesmus,  dysuria,  and  constipation.  Menstruation  was  undisturbetL 
The  tumors  were,  with  one  exception,  so  large  as  to  completely  ob- 
struct the  vaginal  canal,  rendering  operative   interference   necessary- 

*  Winckel,  Arch.  f.  Gynaek,  Bd.  ii,  1871.  pp.  383,  406. 
t  ZwEiFEL,  Arch.  f.  Gynaek.,  Bd.  ix,  p.  39. 

X  RuGE,  Arch.  f.  Gynaek.,  Bd.  ix,  p.  465. 

*  Wiener,  Arch.  f.  Gynaek.,  Bd.  vi,  p.  573. 


ABNORMALITIES   OF   THE   SEXUAL   ORGANS.  539 

In  one  instance  the  contraction,  from  cicatrization  of  the  hydatid  cyst 
following  puncture,  was  so  extensive  as  to  produce  vaginal  stenosis. 
Hydatids  may  be  mistaken  for  exostoses  of  the  bony  pelvis,  for  ha3ma- 
tocele,  malignant  intrapelvic  tumors,  pelvic  abscesses,  or  cellulitis. 
Their  differential  diagnosis  is  based  uj)on  the  presence  in  the  pelvis 
of  smooth,  tense  tumors  not  connected  with  the  uterus,  the  gradual 
development  of  the  tumors  without  constitutional  sym2)toms  of  any 
gravity,  the  presence  of  similar  tumors  in  other  organs,  particularly  in 
the  liver,  the  hydatid  thrill,  which  is  not  often  observed  on  account 
of  the  strong  pressure  to  which  the  cysts  are  exposed,  and,  finally, 
upon  the  examination  of  the  cystic  fluid. 

III.  Uterine  Atresia. — Uterine  atresias,  which  occur  less  frequently 
than  those  of  any  other  portion  of  the  genital  passages,*  may  be  con- 
genital or  accidental,  partial  or  complete.  Complete  atresias,  observed 
in  parturition,  have  become  so  during  pregnancy,  since  conception 
would  not  otherwise  have  occurred. 

Conglutinatio  orificii  externi,  or  adhesion  of  the  lips  of  the  os  ex- 
ternum, is  occasioned  by  the  superficial  union  of  the  opposing  mu- 
cous surfaces  through  the  medium  of  inspissated  epithelium  or  of  new 
connective  tissue  resulting  from  adhesive  inflammation  produced  by 
vaginitis  or  cervical  endometritis.  Schroeder  f  regards  these  atresias 
as  always  incomplete,  and  seeks  their  origin  in  the  gradual  indu- 
ration of  tissues  immediately  surrounding  the  os,  resulting  from  old 
inflammatory  processes.  According  to  his  views,  this  pathological  con- 
dition consists  of  deficient  expansibility  and  not  of  real  contraction 
of  the  OS  externum.  On  examination  no  marked  induration  of  the 
cervix  is  felt.  The  os  externum  is  hardly  perceptible  to  the  touch, 
and  can  often  only  be  discovered  by  inspection.  If  the  examination 
be  made  during  the  first  stage  of  labor  the  internal  os  is  found  widely 
dilated,  while  the  os  externum  remains  persistently  contracted  and 
conveys  a  sensation  to  the  palpating  finger  akin  to  that  produced  by  a 
narrow  and  tense  rubber  band.  If  the  finger  or  an  appropriate  in- 
strument be  firmly  pressed  against  the  os  during  the  pain,  it  slowly 
yields  and  is  gradully  retracted  by  the  longitudinal  cervical  contrac- 
tions. In  default  of  such  simple  interference  the  cervical  tissues 
above  the  os  externum  become  enormously  distended,  and  may  finally 
be  ruptured.  Zweifel  I  refers  this  peculiarly  unequal  dilatation  of 
the  cervical  canal  to  an  abnormal  presentation  of  the  fetal  cranium 
and  to  a  consequent  local  expansion  of  the  anterior  uterine  wall.  The 
OS  externum  having  been  simultaneously  forced  backward  into  the 
hollow  of  the  sacrum,  the  yielding  anterior  uterine  wall  then  forms  a 
diverticulum  which  contains  the  presenting  fetal  part,  and  no  dilating 

*  Jenks,  op.  cif.,  p.  5. 

f  Schroeder.  Lehrbnch,  6te  Aufl.,  p.  487. 

X  Zweifel,  Arch.  f.  Gynaek.,  Bd.  v,  1878,  p.  149. 


540  THE  PATHOLOGY  OF  LABOR. 

force  is  exerted  upon  the  external  os.  Benicke*  was  unable  to  dis- 
cover in  his  cases  the  posterior  deviation  of  the  os  which  is  assumed 
by  Zweifel  as  the  basis  of  his  hypothesis. 

Cicatricial  atresia  of  the  os  externum  is  rarer  than  the  adhesive 
stenosis  just  described.  It  is  usually  confined  to  the  lips  of  the  ex- 
ternal OS,  but  may  involve  the  cervical  canal  for  a  varying  distance. 
Its  most  frequent  causes  are  post-partum  ulceration,  inflammation, 
cauterization  of  the  cervix,  and  mechanical  irritation  applied  for  the 
purpose  of  producing  abortion.  The  diminution  of  the  uterine  dis- 
charges during  pregnancy  affords  a  favorable  ojiportunity  for  the  de- 
velopment of  the  stenosis  under  consideration.  If  cicatricial  atresia 
exist,  the  os  externum  remains  undilated  in  labor,  the  cervix  becomes 
immensely  distended,  and  may  even  rupture,  unless  the  os  be  dilated 
by  artificial  means.  The  diagnosis  rests  upon  the  discovery,  usually 
easily  made,  of  the  cicatrized  os  externum.  Should  the  latter  have 
retreated  into  the  hollow  of  the  sacrum,  the  diagnosis  may  only  be 
accomplished  with  difficulty,  or  the  expanded  cervical  tissues  be  mis- 
taken for  the  fetal  membranes.  This  error  is  avoided  by  the  discovery 
of  the  direct  continuity  of  the  vaginal  wall  and  the  supposed  mem- 
branes, and  by  inspection  through  a  proper  speculum. 

Abnormal  rigidity  of  the  os  externum  is  often  encountered  in  mul 
tiparae  as  the  result  of  genuine  cicatricial  processes  or  of  fibrous  hy- 
pertrophy. This  condition  is  especially  observed  in  connection  Avith 
prolapse  of  the  uterus.  A  similar  rigidity  in  aged  primiparse  is  due 
to  atrophic  degenerative  changes  in  the  cervical  tissues,  or  to  hyper- 
trophy of  the  portio  vaginalis,  f 

I  have  met  in  my  own  practice  witli  an  instance  of  atresia  of  the  os 
internum  and  of  the  adjacent  structures,  the  result  of  cicatrices  from  a 
former  labor.  At  the  time  I  first  saw  her  the  patient  had  been  several 
days  in  labor,  and  the  waters  had  escaped ;  she  had  a  temperature  of 
102°,  and  was  delirious  from  pain  and  exhaustion.  While  preparing 
to  perform  the  Caesarean  section,  rupture  of  the  uterus  suddenly  oc- 
curred, and  the  patient  died  in  a  few  hours. 

Haemorrhages  occurring  into  the  hypertrophied  cervical  tissue  are 
distinguished  as  cervical  thrombi,  and  constitute  obstacles  to  delivery. 
The  retraction  and  dilatation  of  the  cervix  may,  further,  be  obstructed 
by  adhesions  in  the  lower  segment  of  the  uterus  between  the  decidua 
and  the  chorion. 

Acute  elongation  of  the  anterior  lip  of  the  os  externum,  in  conse 
quence  of  its  incarceration  between  the  foetus  and  the  bony  pelvis,  and 
of  the  resulting  cedema  of  its  tissues,  is  referred  to  by  Ilirte  I  as  a  rare 
but  serious  obstacle  to  delivery. 

Parturition  is  sometimes  delayed  by  double  uterus.     The  obstruc- 
*  Benicke,  op.  cif.,  p.  252.  f  Benicke.  op.  ciL,  p.  240. 

X  HiBTE,  Arch.  f.  Gynaek..  Bd  vii,  1875,  p.  552. 


ABNORMALITIES  OF  THE  SEXUAL   ORGANS.  54I 

tion  may  ia  this  instance  be  jDroclucetl  by  an  hypertrophied  unimpreg- 
nated  horn  of  the  uterus.*  Again,  the  oblique  position  of  tlie  im- 
pregnated horn  may  produce  abnormal  presentations  f  or  materially 
interfere  with  the  efficiency  of  the  pains. 

The  uterine  atresias  produced  by  carcinomata,  fibromata,  and  ova- 
rian tumors  are  considered  in  another  chapter. 

Symptoms  of  Atresias  of  the  Genital  Canal. — The  principal  symp- 
toms of  atresia  in  the  unimpregnated  state  relate  to  the  jjartial  or 
complete  retention  of  the  menstrual  fluids.  If  the  stenosis  be  com- 
plete the  uterus  is  enlarged  and  fluctuating,  while  severe  uterine  pains 
attend  each  monthly  period.  J  The  Fallopian  tubes  are  dilated.  Some 
of  the  retained  and  decomposed  menstrual  fluid  may  be  forced  through 
the  tubes  into  the  peritoneal  cavity,  producing  serious  or  fatal  joerito- 
nitis.  The  mere  dilatation  of  the  uterus  may  become  so  excessive  as 
to  produce  peritonitis.*  Septic  poisoning  is  sometimes  induced  by 
absorption  of  putrescent  materials  from  the  uterine  cavity.  A  symp- 
tom often  serving  to  attract  attention  to  the  existence  of  abnormal 
vaginal  contraction  is  inability  to  perform  the  sexual  act. 

The  most  prominent  symptom  of  atresia  during  parturition  con- 
sists, in  general  terms,  of  mechanical  obstruction  to  delivery,  which  is 
more  or  less  serious  in  proportion  to  the  degree  of  existing  stenosis. 
The  special  symptomatology  of  the  individual  pathological  conditions 
productive  of  atresia  has  been  considered  in  connection  with  their 
respective  anatomical  characters. 

Note. — Atresias  for  the  most  part  require  to  be  treated  each  by  itself,  according 
to  the  principles  of  surgical  art,.  In  p.  paper  by  Professor  1.  E.  Taylor,  in  the 
fourth  volume  of  the  Transactions  of  the  American  Gynascological  Society,  entitled 
Atresia  of  the  Vagina.  Congential  or  Accidental,  in  the  Pregnant  or  Non-pregnant 
Female,  the  author  relates  a  case  of  seemingly  complete  imperforation  of  the  vagina 
complicating  labor,  where  he  succeeded,  by  scraping  with  the  finger-nail  during  the 
pains,  in  passing  the  index-finger  through  the  intervening  membrane  to  the  child's 
head,  and  eventually  in  securing  an  opening  large  enough  for  the  birth  to  be  ac- 
complished. I  had  previously  reported  two  similar  cases,  one  in  the  New  York 
Medical  Journal,  and  one  to  the  Obstetrical  Society. ||  The  first,  where  I  was  aided 
by  Professor  Fordyce  Barker,  occurred  in  Bellevue  Hospital,  and  the  second  in 
private  practice.  In  both,  similar  success  followed  a  gradual  dissection  of  the 
A'aginal  walls  with  the  finger.  In  such  cases  usually  a  depression,  or  a  thinned 
point  in  the  tissues,  indicates  the  direction  to  be  followed.  C.  Braun  states,  how- 
ever, that  he  has  seen  three  cases  where  vesico-vaginal  fistulns  were  produced  by 
this  tunneling  process,  an  admonition  to  extreme  caution  in  its  performance.^  For 
stenoses  of  the  vagina,  dilatation  should  be  employed,  either  by  means  of  compressed 

*  MuLLER,  Arcli.  f.  Gynaek..  Bd.  v.  1873,  p.  1.33. 
t  ScHATZ,  Arch.  f.  Gynaek.,  Bd.  ii,  1871.  p.  2D7. 

t  DoHRN,  Arch.  f.  Gynaek.,  Bd.  x,  1876,  p.  544;  I.  E.  Taylor,  Atresia  of  the 
\"agina,  Trans,  of  the  Am.  Gyna?e.  Soc,  vol.  ix,  1880,  pp.  9,  12. 

#  I.  E.  Taylor,  loc.  cit.,  p.  16. 

II  Trans,  of  the  New  York  Obstet.  Soc,  vol,  i,  p.  44. 

•^  I>RAUN  VON  Fernwald,  Lehrbuch  der  gcsammt.  Gynaek.,  p.  273. 


542  THE  PATHOLOGY  OF  LABOR. 

sponges,  the  tampon  of  slippery-elm  (Skene),  or  the  water-bag.     When  dilatation  is 
already  well  advanced,  incisions  may  be  used  to  aid  in  completmg  the  process. 

Uterixe  Tumors  complicating  Pregnancy,  Parturition,  and 
THE  Puerperal  State. 

I.  Uterine  Myomata.— 1.  In  Pregnancy.— Becmse  of  the  disposi- 
tion of  uterine  myomata  to  produce  sterility,  they  naturally  constitute 
comparatively  infrequent  complications  of  pregnancy.  They  are  sub- 
divided, according  to  their  location,  into  subperitoneal,  interstitial, 
and  submucous  myomata.  The  presence  of  either  variety  diminishes 
the  probability  of  conception,  but  none  absolutely  precludes  the  possi- 
bility of  its  occurrence.  In  most  instances,  myomata  produce  no 
symptoms  during  pregnancy,  and  do  not  disturb  labor. 

Subperitoneal  myomata  prevent  conception  and  interrupt  utero- 
gestation  only  when  they  attain  large  dimensions,  and  their  prejudicial 
influence  is  then  usually  referable  to  the  uterine  retroversions  or  retro- 
flexions which  they  induce.  Interstitial  myomata  are  more  likely  than 
the  preceding  variety  to  occasion  abortion  or  premature  delivery,  either 
by  producing  uterine  flexions,  or  by  acting  as  the  exciting  cause  of 
haemorrhages,  which  are  more  severe  when  the  placenta  is  located  over 
the  site  of  the  tumor.  This  statement  applies  particularly  to  post- 
partum  haemorrhages,  inasmuch  as  the  muscular  atrophy  induced  by 
the  moyma  prevents  the  ready  and  complete  closure  of  the  uterine 
sinuses. 

Submucous  myomata  rarely  permit  of  conception,  which,  in  the 
event  of  its  occurrence,  is  almost  uniformly  followed  by  abortion,  due 
usually  to  metrorrhagia.  In  cervical  myomata,  however,  pregnancy 
may  progress  to  its  normal  termination.  Myomata  ordinarily  partici- 
pate in  the  uterine  hypertrophy  of  pregnancy,  becoming  at  the  same 
time  softer  and  more  succulent.  This  change  in  consistence,  which  is 
referred  to  increased  vascularity,  to  colloid  transformation,  and  to  serous 
infiltration,  is  attended  by  dilatation  of  the  lymphatics,  Avhich  may  lead 
to  the  formation  of  cysts.  The  softened  tumor  readily  undergoes 
changes  of  form  under  the  influence  of  increasing  intrapelvic  pressure 
and  of  uterine  traction.  It  may  become  so  flattened  that  it  ceases  to 
be  recognizable  as  a  tumor,  but  regains  its  earlier  shape  after  delivery. 

The  diagnosis  of  uterine  myomata,  particularly  of  the  interstitial 
and  submucous  varieties,  is  often  attended  during  pregnancy  by  diffi- 
culty, inasmuch  as  their  symptoms  and  signs  are  obscured  by  those  of 
pregnancy.  On  the  other  hand,  the  existence  of  myomata  may  pre- 
vent the  recognition  of  pregnancy.  Fibrous  tumors  may  be  mistaken 
for  fetal  organs  or  for  intra-uterine  cystic  tumors.  Careful  palpation 
by  the  combined  method  with  two  fingers  in  the  vagina,  or  the  half 
or  entire  hand  in  the  rectum  if  necessary,  should  be  employed  to  make 
out  the  shape,  position,  and  consistency  of  the  suspected  growth.     As 


ABNORMALITIES  OP  THE  SEXUAL  ORGANS.       '543 

a  further  aid  to  diagnosis,  Landau  recommends  puncture  through  the 
vagina,  by  means  of  which  the  presence  or  absence  of  fluid  and  the 
density  of  the  tissues  penetrated  can  be  determined. 

2.  In  Parturition  and  the  Puerperal  State. — Uterine  polypi  act  as 
impediments  to  deKvery  only  when  they  are  situated  beside  or  in  front 
of  the  advancing  child,  and  are  possessed  of  considerable  size  and  con- 
sistence. If  the  tumor  be  small,  movable,  and  yielding,  it  may  occa- 
sion trifling  obstruction  to  parturition,  and  may  even  be  exj)elled  by  the 
advancing  foetus,  after  rupture  of  its  pedicle. 

Interstitial  myomata,  when  corporeal,  constitute  impediments  to  de- 
livery only  when  located  in  the  lower  segments  of  the  uterus.  Even 
when  thus  situated,  they  often  spontaneously  recede  from  the  pelvic 
cavity  under  the  influence  of  the  longitudinal  uterine  contractions. 
By  exerting  traction  on  the  uterine  parietes  they  aggravate  the  sever- 
ity of  the  pains,  and  sometimes  produce  rupture  of  the  uterine  wall,  in 
which  their  growth  has  already  determined  atrophic  degeneration.  By 
interfering  with  symmetrical  uterine  contraction,  interstitial  myomata 
render  the  pains  irregular  and  inefficient,  besides  predisposing  to  ante- 
and  particularly  to  post-partum  haemorrhage.  By  altering  the  form  of 
the  uterine  cavity  and  preventing  the  engagement  of  the  head  in  the 
superior  strait,  this  variety  of  myoma  frequently  produces  abnormal 
positions  and  presentations.  In  a  case  of  my  own  eclampsia  resulted 
apparently  from  the  same  set  of  causes  as  those  which  obtain  in  multi- 
ple pregnancy.  They  also  predispose  to  the  development  of  retro- 
flexions in  the  puerperal  state.  When  interstitial  myomata  are  de- 
veloped in  the  cervical  tissues  they  almost  invariably  offer  a  mechanical 
impediment  to  delivery,  and  are  rarely  capable  of  being  displaced  above 
the  superior  strait.  If,  however,  they  have  become  intravaginal  and 
their  base  be  not  too  extensive,  they  are  often  readily  amenable  to  ap- 
propriate surgical  interference.  In  default  of  the  latter,  fatal  com- 
pression may  be  exerted  upon  the  fetal  cranium,  or  the  vesico-vaginal 
septum  may  be  lacerated  during  labor. 

Subserous  myomata  are  ordinarily  developed  in  the  posterior  uter- 
ine wall.  If  connected  with  the  body  of  the  uterus  and  located  above 
the  retro-uterine  reflexion  of  the  peritonaeum,  they  may  be  spontane- 
ously extruded  from  the  pelvic  into  the  peritoneal  cavity.  They  origi- 
nate, however,  most  frequently  in  the  cervical  tissues,  and,  extending 
downward,  become  retrovaginal,  more  or  less  completely  occupy  the 
pelvic  cavity,  and  offer,  provided  their  size  be  at  all  considerable,  an 
insurmountable  obstacle  to  parturition.  This  variety  has  been  desig- 
nated as  the  incarcerated  uterine  myoma.  The  prognosis  is  grave,  a 
fatal  termination  having  been  noted  in  one  half  of  the  mothers  and 
in  two  thirds  of  the  children. 

Treatment.— Myomata  in  most  cases,  it  should  be  remembered,  pro- 
duce no  symj)toms  during  i)regnancy,  and  do  not  disturb  labor.     If 


544  THE  PATHOLOGY  OF  LABOR. 

of  small  size,  they  may  escape  observation  altogether.  Their  mere 
presence,  therefore,  does  not  indicate  ground  for  interference.  As  a 
rule,  it  is  well  to  observe  a  waiting  policy  until  the  need  of  assistance 
becomes  evident. 

The  induction  of  abortion  where  the  tumor  threatens  to  disturb 
the  later  progress  of  pregnancy  is  a  questionable  expedient  on  account 
of  the  tendency  to  profuse  haemorrhage,  and  the  difficulty  of  removing 
the  secundines.  Dr.  A.  Kessler  reported  a  case,  which  I  saw  with  him 
in  consultation,  where,  after  the  expulsion  of  a  four  months'  fcetus,  it 
was  found  impossible  to  reach  the  placenta.  The  latter  occupied  an 
inaccessible  position  near  the  right  cornu,  far  out  of  reach  of  the  hand, 
while  the  convexity  of  the  tumor  was  so  great  as  to  interfere  with  the 
working  of  ovum  forceps  or  the  curette.  The  patient  died  of  septi- 
c£emia.     Kemoval  of  the  uterus  would  possibly  have  saved  her  life. 

Kaltenbach  has  reported  a  case  where  he  performed  the  supravagi- 
nal ampvitation  of  the  uterus  between  the  fourth  and  fifth  months  of 
pregnancy,  on  account  of  myomata,  the  largest  of  wliieh  weighed  seven 
pounds.  They  gave  rise  to  unendurable  pressure  and  to  exhausting 
hsemorrhages.     The  patient  recovered. 

T.  Landau  *  has  collected  eighteen  cases  in  wliich  amputation  of 
the  pregnant  uterus  has  been  performed,  owing  to  disturbances  pro- 
duced by  myomata.    Of  these,  eleven  recovered  and  seven  ended  fatally. 

If  the  myomata  are  pedicled  or  subserous  and  of  moderate  size,  their 
removal  during  pregnancy  by  enucleation  is  justifiable  if  they  threaten 
complications.  The  prognosis  is  not  unfavorable,  for  though  in  seven- 
teen operations  collected  by  Landau  four  patients  died,  one  of  these 
had  a  large,  broad-based  multiple  tumor,  one  suffered  from  nephritis, 
and  two  occurred  in  the  days  of  defective  asepsis,  hi  two  of  the  fatal 
cases,  and  in  four  where  recovery  took  place,  abortion  followed.  If 
myomata  encroach  upon  or  occupy  the  pelvic  cavity,  an  attempt  should 
be  made  to  raise  them  above  the  brim  by  sustained  rectal  or  vaginal 
pressure. 

The  most  serious  obstruction  to  the  birth  of  the  child  is  offered  by 
cervical  and  subserous  myomata  which  encroach  upon  the  pelvic  space. 
They  are  of  rare  occurrence.  The  treatment  varies  according  to  the 
intra  or  extravaginal  situation  of  the  growth.  In  both  instances, 
where  the  child  is  living,  operative  interference  should  be  postponed  if 
possible  to  end  of  pregnancy. 

In  the  intravaginal  form,  room  should  be  made  for  the  exit  of  the 
child  by  splitting  the  capsule  and  enucleating  the  myoma.  Bleeding 
from  vessels  should  be  controlled  by  compression  forceps,  and  the 
cavity  should  be  filled,  after  the  expulsion  of  the  child,  with  iodoform 
gauze.     Even  tumors  of  large  size  may  be  enucleated  per  vaginam  if 

*  T.  Landau,  Zur  Behandlnng  derdurch  Mrome  Complicirten  Schwangersehaft 
und  (xeburt.  Klin.  Vortrage,  Neue  Folge,  No.  2G. 


ABNORMALITIES  OF  THE  SEXUAL  OEGANS.  545 

they  are  first  segmented  {^^  mo7'cellement^''  of  Pean),  and  are  then  re- 
moved piecemeal. 

Dr.  P.  F.  Munde  *  has  reported  a  case  of  pregnancy  advanced  to 
the  sixth  month  where  an  interstitial  myoma  of  the  anterior  wall  of  the 
nterus  and  of  the  cervix  filled  the  pelvic  cavity  almost  to  the  vaginal 
orifice.  After  careful  deliberation,  Munde  decided  to  remove  the  tumor 
by  enucleation.  This  he  accomplished  successfully ;  the  tumor  weighed 
three  pounds.  The  foetus  and  placenta  were  then  easily  extracted.  The 
mother  made  a  good  recovery.  Similar  successes  have  been  reported 
by  Schroeder,  Grimsdale  Danyon,  and  Braxton  Hicks.  Depaul  enuc- 
leated the  morbid  growth  in  the  case  of  fibrous  polypus,  with  a  broad 
attachment  (six  to  seven  centimetres)  to  the  cervix.  The  patient  died 
two  months  later,  but  the  tumor  gave  forth  an  extremely  oifensive  odor 
at  the  time  of  the  operation. 

With  small  tumors  it  may  be  possible  to  extract  the  child  first  with 
forceps  or  version,  or  after  craniotomy,  Chambazian  reports  twenty 
forceps  cases,  in  which  twelve  mothers  and  seven  children  were  saved. 
Of  twenty  version  cases,  only  eight  mothers  and  three  children  sur- 
vived. But  even  then  it  is  usually  prudent  to  remove  the  tumor  im- 
mediately after  the  birth  of  the  child,  owing  to  the  danger  of  septic 
infection  incident  to  the  bruising  of  the  tissues.  Then,  on  checking 
the  h?emorrhage,  the  cavity  should  be  filled  with  iodoform  gauze. 

Polypoid  growths  should  be  pushed  back  into  the  uterus,  if  pos- 
sible, in  cases  where  the  pedicle  is  out  of  reach.  When,  however,  the 
tumor  is  shoved  down  in  advance  of  the  head,  and  the  pedicle  is  ac- 
cessible, it  should  be  removed  with  the  ecraseur  or  with  scissors. 
Chambazian  f  reports  eight  cases  of  extirpation  performed  during  jDreg- 
nancy,  on  account  of  haemorrhage,  with  one  death,  due  not,  however 
to  the  operation,  but  to  eclampsia.  In  eight  cases  of  removal  during 
labor  there  was  no  death. 

In  pelvic  obstruction  due  to  extravaginal  myomata  the  growth  is 
usually  of  cervical  origin.  As  a  rule,  it  develops  in  the  pelvic  con- 
nective tissue  behind  the  uterus,  and  is  only  roofed  over  by  the  peri- 
tonaeum. As  the  Caesarean  section  or  the  Porro  operation  is  indicated 
in  these  cases  of  impaction,  it  is  desirable,  unless  the  symptoms  due  to 
pressure  are  urgent,  that  interference  should  be  postponed  to  the  end 
of  pregnancy. 

Sanger  J  collected  forty-three  cases  of  Cfesarean  section  complicated 
by  myomata.  Of  these,  in  thirty  operations  performed  previous  to  1874 
but  two  recoveries  were  reported.  Since  1874  there  have  been  thirteen 
operations,  with  five  recoveries.  Of  these,  in  three  cases — viz.,  in  Tar- 
nier's,  Zweifel's,  and  Agnew's — the  Porro  method  was  followed,  and  all 

*  Munde,  Am.  Jour.  Obstet.,  October,  1884,  p.  1,061. 

f  Chambazian,  Des  fibromes  du  col  de  Tuterus,  Paris,  1883. 

I  Sanger,  Der  Kaiserschnitt  bei  Uterus-Fibromen. 

35 


546  THE  PATHOLOGY  OF  LABOR. 

terminated  fatally.  Of  the  ten  cases  in  which  the  older  method  was 
adopted,  in  five— viz.,  in  those  of  Cazin,  Cornelins  Olcott,  Martin,  San- 
ger, and  Moses  Baker — the  patients  recovered.  In  four  of  the  five  fatal 
cases,  the  particulars  are  furnished  in  four.  In  that  of  Netzel,  the 
membranes  ruptured  three  days  before  the  operation ;  in  McCormack's, 
the  patient  had  been  fifteen  days  in  labor,  and  general  peritonitis  exist- 
ed ;  in  T.  G.  Thomas's,  the  membranes  had  ruptured,  and,  previous  to 
operating,  unsuccessful  attempts  at  delivery  had  been  made  by  means 
of  version,  craniotomy,  and  embryotomy  ;  in  Spiegelberg's,  no  contrac- 
tion followed  the  section,  and  the  patient  died  from  exhaustion  due  to 
hasmorrhage. 

Since  the  appearance  of  Sanger's  memorable  work,  of  seven  cases 
where  his  method  was  employed  in  consequence  of  myomata,  only  that 
of  Leopold  recovered.  In  the  cases  which  terminated  fatally  the 
patients  were,  however,  all  in  a  septic  condition  at  the  time  of  the  opera- 
tion. Still,  owing  to  the  excessive  vascularity,  the  imperfect  contrac- 
tility, and  the  hindrances  to  drainage  in  myomatous  uteri,  the  condi- 
tions at  present  favor  a  resort  to  the  Porro  method.  Successes  have 
been  reported  by  Schroeder,  Hofmeier,  von  Ott,  and  L.  Landau.,  in  cases 
where  the  extraction  of  the  child  was  followed  by  the  removal  of  the 
uterus.  In  each  the  intro-abdominal  method  was  employed  in  the 
treatment  of  the  stump. 

Landau's  case  was  especially  instructive.  Tlie  abdominal  incision  extended 
from  the  symphysis  to  a  hand-breadth  above  the  navel.  The  uterus  was  turned 
out,  and  after  tlie  adjustment  of  a  rubber  ligature  the  child  was  removed  alive 
by  the  uterine  incision.  In  bringing  the  uterus  forward  the  retro-uterine  and 
retro-cervical  tumor  was  dragged  out  of  the  pelvic  cellular  tissue  in  which  it 
was  imbedded.  The  elastic  ligature  was  placed  below  the  entire  uterus,  the 
ovaries,  and  the  tumor,  the  uterus  was  severed,  and  the  tumor  was  enucleated. 
The  raw  surfaces  of  the  stump  were  first  united  by  eight  deep  sutures,  which 
likewise  included  the  bed  of  the  tumor,  and  then  the  peritonaeum  was  drawn 
from  the  sides  to  cover  the  wound.  In  this  case  it  was  thought  best  to  em- 
ploy drainage  through  Douglas's  cul-de-sac  by  means  of  iodoform  gauze,  owing 
to  the  enormous  serous  transudation  of  the  tissues.  The  gauze  was  changed  at 
the  end  of  forty-eight  hours,  and  on  the  fourth  and  sixth  days.  On  the  seventh 
day  the  wound  was  allowed  to  heal.  The  patient  left  the  liospital  after  three 
and  a  half  weeks.  The  child  weighed  seven  pounds  at  its  birth,  and  throve 
afterward.     (Klinische  Vortrage,  N.  F.,Ko.  26.) 

Ott,  after  removing  uterus  and  ovaries,  left  the  retro-uterine  tumor  in  situ. 
The  wound  was  closed  by  a  triple-stage  suture.  As  a  consequence  of  the  re- 
moval of  the  ovaries,  the  myoma  rapidly  shrank  to  small  dimensions.  (Arch, 
f.  Gynaek.,  Bd.  xxxvii,  p.  88.) 

II.  Carcinoma  of  the  Cervix  Uteri.— 1.  In  Pregnancy. — Uterine 
cancer,  which  is  one  of  the  gravest  comj^lications  of  pregnancy,  is,  if 
primary,  almost  without  exception  of '  cervical  origin.  Conception 
often  occurs  in  the  earlier  stages  of  the  disease,  and  since  it  is  only 


ABNORMALITIES  OP  THE   SEXUAL  ORGANS.  547 

absolutely  prevented  by  a  carcinoma  which  completely  occludes  the 
cervical  canal,  it  occasionally  takes  place  even  in  the  later  stages  of 
the  neoplasm's  growth.  The  existence  of  j^regnancy  usually  hastens 
the  development  of  the  cancer,  the  more  rapid  growth  of  which  is 
probably  referable  to  the  increased  vascularity  of  the  uterus  and  to 
the  correspondingly  augmented  activity  of  its  nutritive  processes.  In 
rare  instances  the  occurrence  of  pregnancy  seems  to  arrest  the  devel- 
opment of  the  local  and  general  symptoms  referable  to  the  cancerous 
growth.  In  the  majority  of  cases  the  neoplasm  does  not  interfere 
with  the  completion  of  normal  utero-gestation,  although  abortion  or 
premature  delivery  is  a  frequent  result  of  its  development.  These 
issues  of  pregnancy  are  most  frequently  determined  by  cancerous  tu- 
mors whose  progress  has  invaded  the  higherj  supravaginal  portions 
of  the  cervix,  and  is  probably  occasioned  by  the  interference,  on  the 
part  of  the  neoplasm,  with  the  normal  process  of  uterine  growth  and 
expansion.  The  traction  exerted  by  the  enlarging  cervix  upon  the 
unyielding  tissues  of  the  tumor  may  also  produce  a  solution  of  their 
continuity,  and  give  rise  to  formidable  haemorrhage.  In  very  excep- 
tional cases  uterine  carcinoma  seems  to  protract  the  period  of  gestation 
far  beyond  its  normal  limits,  in  which  case  the  foetus  dies  and  under- 
goes the  changes  usual  in  retention. 

2.  1)1  Parturition  and  the  Piierperal  State. — If  the  cancer  be  con- 
fined to  the  lower  margin  of  the  cervical  canal,  the  expansion  of  the 
latter  is  not  materially  interfered  with,  and  delivery  may  be  safely  and 
speedily  accomplished.  If,  however,  the  morbid  process  has  involved 
the  entire  portio  vaginalis,  or  has  even  extended  quite  to  the  os  inter- 
num, the  inelastic  tissue  of  the  cancerous  growth  has  replaced  the  ex- 
pansile muscular  fibers,  and  an  opening  of  sufficient  caliber  for  the 
passage  of  the  foetus  can  only  be  produced  by  rupture  and  contusion 
of  the  degenerated  and  unyielding  cervix.  The  immediate  result  of 
such  a  laceration  is  violent  haemorrhage,  which  is,  however,  quite 
amenable  to  treatment.  The  consequence  of  the  excessive  pressure 
to  which  the  cervix  is  subjected  during  labor  is  necrosis  of  the  con- 
tused tissues,  which  is  frequently  followed  by  fatal  sejiticaemia. 

The  diagnosis  is  accomplished  by  the  same  means  which  are  em- 
ployed in  the  detection  of  cervical  cancer  in  the  unimpregnated  con- 
dition. 

The  prognosis  is  doubtful  for  both  mother  and  child.  The  latter 
is  imperiled  by  its  liability  to  premature  expulsion,  and  by  the  me- 
clianical  obstruction  to  its  birth  produced  by  the  tumor.  The  moth- 
er's life  is  not  only  shortened  by  the  rapidity  of  the  cancerous  growth 
usually  induced  by  pregnancy,  but  is  jeopardized  by  her  increased  lia- 
bility to  abortion,  post-partum  haemorrhage,  and  puerperal  fever. 

Treatment. — During  pregnancy,  in  cases  where  the  disease  is  con- 
fined to  the  cervical  portion,  either  amputation  or  excision  should  be 


548  THE  PATHOLOGY  OF  LABOR. 

performed.  The  time  selected  for  operation  is  usually  the  fourth 
month.  Abortion  does  not  necessarily  follow.  In  advanced  stages, 
where  the  carcinomatous  process  has  invaded  the  contiguous  tissues, 
operative  interference  should  be  postponed  until  the  end  of  gestation. 
Just  in  proportion  as  the  outlook  for  the  mother  grows  questionable, 
the  interests  of  the  child  rise  in  importance.  An  extensive  removal 
of  diseased  tissue  during  pregnancy  exposes  the  mother  to  the  imme- 
diate dangers  of  j)remature  labor  and  subsequent  septicaemia.  Upon 
the  advent  of  labor,  if  the  child  be  living,  and  the  upper  vaginal  tis- 
sues are  largely  involved,  the  Caesarean  section  or  the  Porro  operation 
certainly  holds  out  the  hope  of  saving  one  life,  and  probably  does  not 
greatly  increase  the  peril  to  which  the  other  is  exposed.*  Dr.  Fordyce 
Barker  stated  that  he  met  with  three  cases  of  spontaneous  delivery 
where  the  cervix  was  carcinomatous,  in  all  of  which  the  mother  sur- 
vived the  childbed  period.  Such  good  fortune,  however,  is  necessarily 
rare,  and  is  only  likely  to  result  in  j^atients  whose  tissues  are  but  mod- 
erately affected.  Frommel  f  reports  a  case  from  the  Berlin  Clinic 
where,  the  child  being  dead,  Schroeder  broke  away  with  his  hands 
large  masses  of  the  neoplasm,  and  thus  provided  a  passage  of  sufficient 
size  to  permit  the  extraction  of  the  child  by  version.  The  patient  was 
discharged  on  the  tenth  day,  but  died  a  few  days  after.  Alfred  Gon- 
ner  |  recommends  that  labor  be  allowed  to  proceed  until  dangerous 
symptoms  call  for  active  measures,  or  the  limit  of  physiological  dilata- 
tion is  reached.  Then,  if  the  vagina  is  not  too  extensively  implicated, 
by  means  of  incisions  and  the  partial  extirpation  of  the  diseased  mass 
with  the  galvano-caustic  wire,  the  thermo-cautery,  and  volsella  forceps, 
room  should  be  made  for  the  extraction  of  the  child  by  forceps,  or  after^ 
version.  Of  four  cases  thus  treated,  the  mothers  all  recovered  from 
the  immediate  effects  of  the  operation,  and  three  of  the  children  were 
born  living. 

III.  Ovarian  Tumors. — 1.  In  Pregnancy. — Ovarian  tumors,  par- 
ticularly those  of  the  cystic  variety,  are  quite  often  encountered  as 
complications  of  pregnancy.  They  usually  antedate  conception,  but 
may  make  their  aj^pearance  during  pregnancy.  Utero-gestation  often 
favors  their  development  by  increasing  the  general  vascularity  of  the 
pelvic  viscera,  although  an  arrest  of  growth  and  an  actual  retrogress- 
ive metamorphosis  of   the  tumor  seem  to  be  the  occasional  effect  of 

*  Herman  (Trans,  of  the  Obstet.  Soc,  of  London,  vol.  xx,  p.  191)  reports  twelve 
Caesarean  operations,  with  four  recoveries.  In  a  case  reported  by  the  author  in 
1887,  the  patient  lived  two  months  after  the  Caesarean  section,  and  then  succumbed 
to  the  ravages  of  the  cancerous  affection.  The  child  has  thriven  up  to  date — 1881. 
lieopold  has  performed  the  Porro  operation  twice  for  carcinoma  with  success, 

f  Frommel,  Zur  operat.  Therapie  d.  Cervix-Carcinoms  in  d.  Complication  mit 
Graviditat,  Ztschr.  f.  Geburtsh.  und  Gynaek.,  Bd.  v,  p.  158. 

X  GoNXER,  Zur  Therapie  der  durch  Carcinora  des  Uterus  complicirten  Schwanger- 
schaft  und  Geburt,  Ztschr.  f.  Geburtsh,  und  Gynaek.,  vol.  x,  p.  7. 


I 


ABNORMALITIES  OF  THE  SEXUAL  ORGANS.  549 

intercurrent  conception.*  This  retrogressive  process  affects  only  cys- 
tic tumors,  and  may  result  from  the  uterine  pressure,  which  facilitates 
the  absorption  of  their  contents.  After  delivery  the  cysts  present  on 
palpation  a  relaxed  and  flabby  condition.  The  natural  tension  of  the 
tumor  is  soon  restored  by  the  secretion  of  additional  fluid,  except  in 
those  rare  cases  in  which  the  compression  of  the  gravid  uterus  seems 
to  initiate  a  permanent  process  of  retrogression  and  absorption. 

Wernich  f  advanced  the  opinion  that  the  assumption  by  benign 
ovarian  tumors  of  a  malignant  character  is  determined  by  the  occur- 
rence of  pregnancy,  and  Spiegelberg  J  regards  this  transition  as  posi- 
tively established.  The  ovarian  tumors  under  consideration  may  be 
bilateral.  If  they  be  of  moderate  dimensions,  they  may  not  interfere 
with  utero-gestation  or  delivery,  except  by  a  slight  aggravation  of  the 
usual  disturbances  attendant  upon  pregnancy.  An  ovarian  tumor  is, 
however,  liable  to  occasion  abortion  or  premature  delivery  if  it  be  con- 
fined by  adhesions  to  the  pelvic  cavity,  or  be  closely  connected  to  the 
uterus.  Under  these  circumstances,  abortion  results  from  interference 
on  the  part  of  the  new  growth  with  the  natural  uterine  expansion,  or 
from  the  retroflexion  which  it  induces.  In  rare  instances  a  rotation 
of  the  cyst  upon  its  axis,  followed  by  strangulation  of  its  pedicle,  is 
observed.  This  deplorable  accident  leads  to  a  lethal  issue  by  shock, 
by  gangrene  of  the  cyst  and  consequent  sejDticsemia,  or  by  heemorrhage 
into  the  tumor  and  the  peritoneal  cavity,  followed  by  peritonitis.  The 
rationale  of  the  morbid  phenomena  referable  to  tumors  of  larger  size 
is  entirely  different.  These  tumors  do  not  often  occasion  abortion  or 
premature  delivery,  but  gravely  complicate  the  later  periods  of  preg- 
nancy by  means  of  the  pressure  which  they,  in  common  with  the  gravid 
uterus,  exert  upon  the  abdominal  and  thoracic  viscera.  Ascites  and 
dyspnoea  are  the  chief  results  of  the  augmented  intra-abdominal  ten- 
sion. (Edema  of  the  lower  extremities  is  often  observed.  The  ova- 
rian cyst  sometimes  ruptures  and  produces  fatal  collapse,  peritonitis, 
or  septicemia.  The  escaped  cystic  fluid  may,  however,  be  absorbed, 
and  pregnancy  reach  a  natural  termination. 

Diagnosis. — If  the  ovarian  tumor  be  of  small  size,  it  may  be  com- 
pletely masked  by  the  growing  uterus,  or  may  be  mistaken  for  a  por- 
tion of  the  latter.  If,  on  the  other  hand,  the  surface  of  the  tumor  be 
irregular  and  nodular,  the  uterus  may,  at  an  early  period  of  pregnancy, 
itself  be  regarded  as  a  part  of  the  cyst.  Palpation  and  auscultation 
will,  however,  usually  afford  satisfactory  diagnostic  points  of  differen- 
tiation. Especially  the  softness  of  the  pregnant  uterus  contrasts  with 
the  tense  condition  of  an  ovarian  cyst.  Moreover,  the  absence  of  the 
menses  in  patients  with  an  ovarian  tumor,  and  an  unusually  rapid  in- 

*  ScHROEDER,  Lehrbuch,  p.  309. 

f  Wernich,  Beitr.  z.  Oeburtsh.  u.  Gyn.,  Bd.  ii,  p.  143, 

X  Spiegelberg,  Lehrbuch,  p.  297. 


550  THE  PATHOLOGY  OF  LABOR. 

crease  iu  the  dimensions  of  the  abdomen,  shonld  awaken  the  suspicion 
of  combined  pregnancy  and  ovarian  tumor. 

3.  In  Parturition  and  the  Ptmyeral  State.— The  dangers  result- 
ing in  parturition  and  the  puerperal  state  from  ovarian  tumors  com- 
plicating pregnancy  are  twofold,  and  consist  (a)  in  the  obstruction 
to  labor  which  they  occasion  and  (b)  in  the  results  of  the  morbid  pro- 
cesses determined  in  the  neoplasms  themselves  by  the  excessive  press- 
ure of  the  surrounding  tissues. 

(a)  If  the  ovarian  tumor  is  confined  within  the  true  pelvis  in  such 
a  way  as  to  render  its  spontaneous  or  manual  displacement  impossible, 
it  may  offer  a  most  serious  impediment  to  the  expulsion  of  the  fa3tus. 
Dermoid  cysts  manifest  a  more  decided  tendency  to  contract  adhesions 
in  the  pelvis  than  other  ovarian  tumors,  and  afford  on  this  account,  as 
well  as  because  of  the  greater  consistence  of  their  contents,  a  worse 
prognosis  than  any  other  variety.*  Obstructed  labor  more  frequently 
results  from  the  presence  of  small  than  from  that  of  large  ovarian  tu- 
mors, since  the  latter  oftener  escape  into  the  abdominal  cavity  during 
pregnancy,  and  are  unable  at  any  subsequent  period  to  effect  an  en- 
trance into  the  true  pelvis. 

(b)  Even  if  the  obstacle  offered  to  parturition  by  an  ovarian  tu- 
mor be  trivial,  the  changes  induced  in  its  own  substance  by  the  par- 
turient act  may  be  productive  of  very  serious  results.  The  pressure 
and  traction  exerted  upon  the  pedicle  of  the  cyst  are  often  so  severe 
as  to  produce  its  strangulation,  followed  by  necrosis  of  the  tumor, 
with  consequent  septic  poisoning.  Rupture  of  the  sac,  with  its  fatal 
consequences,  may  also  occur,  or  such  severe  contusions  of  the  tumor 
may  be  occasioned  by  excessive  pressure  as  to  result  in  gangrene  of 
its  entire  mass.  The  development  of  the  foetus  is,  as  a  rule,  not  inter- 
fered with  by  ovarian  tumors.  The  latter  manifest  a  tendency  to  very 
rapid  development  in  the  puerperal  state,  except  in  those  rare  cases 
characterized  by  permanent  retrogressive  metamorphosis  and  absorp- 
tion. 

Ovarian  tumors  are  a  dangerous  complication  of  pregnancy  and 
labor.  Jetter  collected  215  cases  with  04  deaths.  Fortunately,  how- 
ever, the  results  of  ovariotomy  are  as  favorable  in  the  pregnant  as  in 
the  non-pregnant  state.  The  operation  does  not  necessarily  interfere 
with  the  continuance  of  gestation.  So  soon  as  the  existence  of  an  ova- 
rian tumor  is  recognized,  therefore,  in  a  pregnant  woman,  its  imme- 
diate removal  is  indicated,  f     When  the  time  is  a  matter  of  election  the 

*  SCHROEDER,  op.  cif.,  p.  501 . 

t  Olshausex  (Krankheiten  der  Ovarien)  188G.  collected  82  operations  performed 
by  44  operators.  There  were  eight  deaths,  four  of  which  took  place  before  the  days 
of  antisepsis.  Olshausen  operated  fourteen  times.  Four  of  the  mothers  aborted 
and  two  died.  Schroeder  {Vide  Straty,  Ztschr.  fiir  Geb.  und  Gynaek.,  vol.  xii.  p. 
268)  operated  fourteen  times.  All  the  mothers  recovered.  Twelve  of  the  children 
(including  twins)  went  to  terra.    Spencer  Wells  operated  ten  times.     Nine  women 


ABNORMALITIES  OB^  THE  FCETUS.  551 

operation  should  be  performed  early  in  pregnancy.  In  the  later 
months  the  conditions  are  less  favorable,  owing  to  the  excessive  vascu- 
larity of  the  pelvic  organs  and  the  consequent  development  of  the  ves- 
sels in  the  pedicle.  Pippingskold,  however,  operated  successfully  ujion 
a  woman  seven  hours  before  the  birth  of  a  full-term  child. 

The  alternative  of  ovariotomy  consists  in  abiding  the  end  of  preg- 
nancy, and  then,  when  the  tumor  interferes  with  the  birth  of  the  child, 
in  pushing  it  uj)ward  above  the  pelvis  or,  failing  after  repeated  effort, 
in  puncture  of  the  cyst.  The  cul-de-sac  of  the  vagina  affords  generally 
the  most  convenient  point  for  the  introduction  of  the  trocar.  The  best 
time  for  tapping  is  during  the  existence  of  a  pain,  when  the  cyst  is 
rendered  tense  by  pressure. 


CHAPTER  XXIX. 

ABNORMALITIES  OF  THE  FCETUS  WHICH  OFFER  AN  OBSTRUC- 
TION TO  DELIVERY. 

Premature  ossification  of  the  cranium. — Hydrocephalus. — Encephalocele. — Hydro- 
thorax. — Ascites. — Other  causes  of  abdominal  distention. — Tumors  of  the  trunk. 
— Monstrosities. — Double  monsters. — Acardiaci. — Anoncephalous  monsters. — 
Abnormal  positions. — Spontaneous  version. — Spontaneous  evolution. 

I.  Fetal  Diseases  which  obstruct  the  Expulsion  of  the 

Head. 

Premature  Ossification  of  the  Fetal  Cranium. — This  condition  is 
characterized  by  the  complete  or  nearly  complete  closure  of  the  fonta- 
nelles.  The  head,  therefore,  loses  its  compressibility,  and  no  longer 
undergoes  those  changes  of  form  which  constitute  so  imjjortant  a  part 
in  the  mechanical  processes  of  delivery.  As  the  anomaly  is  apt  to  in- 
terfere with  brain  development  in  infancy,  the  late  Dr.  John  E.  Blake  * 
advocated  early  jaerforation  where  the  interests  of  the  mother  had  to 
be  consulted.  As  I  have  never  met  with  this  form  of  dystocia  in  a 
large  number  of  instrumental  deliveries,  I  can  not  but  regard  it  as 
extremely  uncommon. 

Hydrocephalus. — Congenital  hydrocephalus  of  sufficiently  marked 
development  to  constitute  an  impediment  to  parturition  is  compara- 
tively rare,  occurring,  according  to  the  statistics  of  Madame  La  Cha- 
pelle,f  only  fifteen  times  in  43,545  deliveries.  It  consists  usually  in  a 
serous  effusion  confined  to  the  cerebral  ventricles.     The  effusion  may, 

recovered  and  went  to  terra.     A.  Martin  reports  three  ovariotomies.     The  mothers 
recovered.     Pregnancy  was  not  interrupted. 

*  Blake,  Am.  Jour,  of  Obstet.,  vol.  ii,  1879,  p.  225. 

f  Spiegelberg,  Lehrbuch,  p.  525. 


552 


THE  PATHOLOGY  OF  LABOR. 


however,  according  to  Jaccoud  and  Hallopean,*  be  situated  in  the 
meshes  of  the  pia  mater,  in  the  cerebral  parenchyma,  in  the  subarach- 
noid cavity,  or  between  the  arachnoid  and  the  dura  mater. 

Etiology.— The  etiological  factors  of  the  disease  have  not  been  as- 
certained, although  Herrgott  f  assumes  an  invariable  causative  relation 
between  coexisting  cretinism  and  hydrocephalus. 

Morbid  Anatomy. — The  accumulated  serum  compresses  the  cerebral 
parenchyma  and  produces  dilatation  of  the  cranial  cavity,  which  may 
become  excessive.  The  cranial  bones  become  abnormally  thin,  being 
in  some  instances  no  thicker  than  parchment.  Their  continuity  may 
be  interrupted  by  apertures  of  varying  size,  through  which  the  con- 
tents of  the  cranium  may  protrude,  constituting  an  encephalocele. 
The  skull  is  of  disproportionate  magnitude  as  compared  with  the  face. 
The  head  may  attain  the  dimensions  of  that  of  an  adult.  The  fore- 
head is  prominent  and  bulging,  the  sutures  are  widely  open,  and  the 
fontanelles  of  large  diameter.  The  body  of  the  foetus  is  usually  well 
developed,  and  of  a  size  corresponding  to  the  existing  period  of  preg- 
nancy, although  spina  bifida  and  other  malformations  may  coexist. 
Hydramnion  frequently  complicates  hydrocephalus. 

Diagnosis. — Cystic  tumors,  spina  bifida,  encephalocele,  and  the 
skull  of  a  macerated  foetus,  are  most  frequently  mistaken  for  hydro- 
cephalus. The  differential  diagnosis  is  based  upon  different  signs,  ac- 
cording to  the  position  and  presentation  of  the  foetus.  If  the  head 
present  and  be  still  above  the  superior  strait,  abdominal  palpation  may 
sometimes  detect  a  large,  rounded,  and  hard  tumor  above  the  pubes, , 
while  auscultation  discovers  the  maximum  intensity  of  the  fetal  cardiac 
sounds  above  the  umbilicus.  The  abdomen  is  unusually  distended.  If 
the  head  has  descended  somewhat  into  the  pelvic  cavity,  palpation  per 
vaginam  reveals  a  fluctuating  sac,  which  becomes  notably  tense  during 
the  jiains.  In  the  interval  between  the  uterine  contractions,  the  broad 
fontanelles,  the  thin  bones,  and  the  wide  sutures  are  readily  felt. 
These  signs  may,  however,  fail  if  the  cranial  bones  be  thick  and  the 
sutures  already  ossified.  In  this  case  the  disproportion  between  the 
forehead  and  face,  the  bulging  frontal  bone,  and  the  prominence  of  the 
superciliary  ridges  are  important  aids  to  a  diagnosis.  If  tlie  mem- 
branes be  ruptured,  the  hairy  scalp  may  be  felt.  The  diagnosis  is  easier 
when  the  cranial  cavity  is  not  greatly  distended.  In  case  of  a  breech 
presentation,  the  diagnosis,  which  is  then  more  difficult,  must  chiefly 
rest  upon  the  detection,  at  the  fundus,  of  a  tumor  larger  than  the  nor- 
mal fetal  cranium.  The  previous  occurrence  of  hydrocephalus  in  the 
same  subject  and  feeble  fetal  movements  may,  in  this  instance,  slightly 
facilitate  the  task  of  the  diagnostician. 

*  Nouv.  diet,  de  med.  et  chir.prat.,  vol.  xiii,  article  Eneophale,  p.  151. 
t  Herrgott,  Des  mal  foetal,  q.  peuvent  faire  obstacle  a  raccouch.,  Paris,  1878, 
p.  13. 


ABNORMALITIES  OP   THE   FCETUS.  553 

Mechanism  of  Delivery. — The  course  of  parturition  is  sometimes 
not  materially  impeded  even  by  a  largely  developed  hydrocephalic  foe- 
tus. This  may  be  due,  if  the  bones  be  attenuated,  to  the  ready  mold- 
ing of  the  fetal  cranium  to  the  pelvis,  or  to  rupture  of  the  head  and 
escape  of  the  serum,  which  event  occurs  chiefly  in  breech  presentations. 
The  presentation  materially  affects  the  course  of  delivery.  If  the  head 
be  forced  with  its  greatest  circumference  against  the  superior  strait, 
it  adapts  itself  less  readily  to  the  pelvis  than  when  it  impinges  later- 
ally or  obliquely  on  the  pelvic  entrance.  The  difficulties  of  delivery  are 
increased  if  the  cranial  bones  be  firm  and  thick,  or  the  sutures  ossified. 
Breech  presentations  are  favorable  to  a  speedy  delivery,  in  that  the 
head  is  subjected  during  its  descent  to  more  equable  pressure  by  the 
pelvic  parietes,  and  therefore  assumes  a  conical  shape  best  adapted  to 
insure  its  easy  expulsion.  Spontaneous  delivery  is,  however,  rare.  In 
the  vast  majority  of  cases  operative  interference  becomes  necessary. 

Prognosis. — The  child's  life  is  usually  sacrificed  if  the  anomaly  be 
sufficiently  marked  to  considerably  protract  parturition.  Even  if  the 
child  be  born  alive,  it  will  probably  succumb  at  an  early  period  of  ex- 
tra-uterine life.  The  prognosis  with  reference  to  the  mother  depends 
largely  upon  the  time  at  which  obstetrical  aid  is  extended,  and  upon 
the  nature  of  the  remedial  measures  adopted.  If  the  labor  be  too  long 
protracted,  vesico- vaginal  fistula  may  result  from  pressure  of  the  fetal 
head,  or  the  mother  may  die  from  exhaustion  or  from  rupture  of  the 
uterus.  Eupture  of  the  uterus  is  comparatively  frequent,  having  oc- 
curred in  sixteen  out  of  seventy-four  cases  of  hydrocephalus  collected 
by  Thomas  Keith.  The  laceration  usually  occurs  in  the  vicinity  of 
the  cervix,  but  is  often  located  at  the  fundus  uteri.  The  treatment 
consists  in  puncturing  the  head  with  a  fine  trocar  and  allowing  the 
fluid  to  escape.  If  practicable,  the  child  should  be  subsequently  turned 
and  extracted  by  the  feet.  The  forceps  is  useless,  as  it  can  not  be 
made  to  take  a  firm  hold.  If  version  is  found  to  be  attended  with  dif- 
ficulty, the  opening  should  be  enlarged,  and  the  head  extracted  with 
the  cranioclast.  If  the  child  is  extracted  by  the  breech  without  pre- 
vious perforation  ^of  the  head,  in  cases  of  difficulty,  Tarnier  recom- 
mends section  of  the  vertebral  column  and  the  withdrawal  of  the  cra- 
nial fluid  by  means  of  an  elastic  catheter  passed  to  the  brain  through 
the  spinal  canal. 

Congenital  Encephalocele. — This  abnormality  of  the  fetal  cranium 
consists  in  the  accumulation  beneath  the  scalp  of  cephalic  fluid,  with 
or  without  an  investment  of  meningeal  or  of  cerebral  tissue.  The  sac 
containing  the  fluid  is  attached  to  the  cranium  by  a  pedicle  of  varying 
length  and  form.  The  aperture  through  which  the  fluid  originally 
contained  within  the  cranium  finds  exit  may  be  produced  by  attenu- 
ation of  the  cranial  bones  attendant  upon  hydrocephalus,  or  may  be 
due  to  arrested  development.     In  some  instances  the  encephalocele  is 


gg^  TUE   PATHOLOGY   OF   LABOR. 

found  still  communicating  with  the  cranial  cavity  through  its  pedicle, 
but  in  others  the  latter  is  impervious.  Encephaloceles  vary  in  size 
from  hardly  perceptible  sacs  to  tumors  of  larger  circumference  than 
the  cranium  itself.  They  may  occupy  any  part  of  the  periphery  of 
the  head,  but  are  most  frequent  in  the  frontal  and  occipital  regions.* 
The  head  may  itself  be  hydrocephalic  or  normal.  The  cause  of  the 
anomaly  in  question  is  not  definitely  known,  but  is  inferred  to  be  of 
inflammatory  nature. 

Encephaloceles  rarely  obstruct  delivery,  because,  their  most  fre- 
quent seat  being  in  the  frontal  or  occipital  region,  they  are  expelled 
either  before  or  after  the  head.  Their  presence  seems  to  determine 
nutritive  changes  in  the  cranial  bones,  whereby  the  latter,  being  ren- 
dered softer  and  more  yielding,  are  more  readily  expelled.  The  amount 
of  obstruction  caused  by  the  encephalocele  will  reach  its  maximum 
when  the  size  is  large,  the  pedicle  short,  and  the  seat  lateral ;  but  simple 
puncture  usually  suffices  to  evacuate  the  sac,  and  obviates  further  diffi- 
culty. The  prognosis  for  both  mother  and  child  is  far  better  than  in 
cases  of  congenital  hydrocephalus. 

II.  Abnormal  Conditions  of  the  Fcetus  •which  obsteuct  the 
Expulsion  of  the  Trunk. 

Hydrothorax,  unattended  by  serous  effusion  into  any  other  of  'le 
closed  cavities  of  the  body,  is  infrequent,  and  when  present  is  rardy 
of  sufficient  extent  to  offer  any  impediment  to  delivery.  Spiegelberg 
encountered  only  one  such  case,  and  refers  to  but  two  others  observed 
by  Hohl.f 

Ascites,  although  more  frequent  than  hydrothorax,  ordinarily  con- 
stitutes an  insignificant  obstruction  to  parturition,  on  account  of  the 
yielding  character  of  the  abdominal  Avails  and  the  small  amount  of 
fluid  usually  present.  It  has,  however,  in  some  instances  markedly 
retarded  delivery.;]; 

Ascites  and  hydrothorax  are  more  frequently  associated  than  iso- 
lated, and  present,  when  combined,  no  inconsiderable  obstruction  to 
delivery.  Pericardial  effusions  of  varying  magnitu(fe  may  exist  simul- 
taneously with  either  or  both  of  these  affections.* 

The  size  of  the  fetal  abdomen  may  be  so  much  augmented  by  dis- 
tention or  enlargement  of  its  viscera  as  to  obstruct  labor.  Among  the 
causes  of  abdominal  distention  from  this  source  may  be  cited  : 

{a)  Cystic  degeneration  of  the  kidneys ;  ||  (b)  dilatation  of  the  uri- 

*  Herrgott,  op  cit,  p.  121.  .  f  Spieoelberg,  Lehrbuch,  p.  528. 
X  Martin,  Monatssehr.  f.  Geburtsk.,  Bd.  xxvii,  180G,  p.  28. 

*  Herrgott,  op.  cit.,  p.  155. 

II  CuMMixs,  Dublin  Jour,  of  Med.  Sci.,  May,  1873,  p.  499 ;  Voss,  Monatssehr.  f. 
Geburtsk.,  Bd.  xxvii,  1866,  p.  28;  Kanzow,  Ibid.,  Bd.  xiii,  1859,  p.  182;  Weg- 
SCHEIDER,  Ibid.,  Bd.  xxvii,  1866,  p.  27. 


ABNORMALITIES   OF   THE   FCETUS.  555 

nary  bladder ;  *  (c)  dilatation  of  the  ureters ;  f  (d)  fibro-cystic  degen- 
eration of  a  testicle  still  retained  in  the  abdomen ;  J  (e)  enlargement 
of  the  liver,  due  to  degenerative  processes;*  (/)  enlargement  of  the 
uterus,  produced  by  secretions  accumulated  in  its  cavity,  the  cervix 
being  impermeable  ;  ||  (g)  enlargement  of  the  pancreas ;  ^  (h)  enlarge- 
ment of  the  spleen ;  ()  (i)  one  fcetus  included  within  another.  In  this 
case  one  foetus  is  completely  invested  by  the  integument  of  the  other, 
and  is  attached  to  the  latter  by  a  pedicle,  which  is  usually  inserted 
either  in  the  sacro-coccygeal,  perineal,  or  cervical  regions.  I  A  case 
of  extensive  anasarca  of  the  foetus,  characterized  by  the  peculiar  gelati- 
nous nature  of  the  fluid  contained  in  the  subcutaneous  cellular  tissue, 
is  reported  by  Keiller  to  have  produced  dystocia.  Emphysema  of  the 
entire  fetal  trunk  may  result  from  putrefaction  occurring  in  the  tissues 
of  a  child  retained  for  some  time  in  utero  after  the  escape  of  the  am- 
niotic fluid.  •  The  putrefactive  processes  owe  their  origin  to  the  en- 
trance of  air  within  the  uterus.  The  gaseous  products  of  decomposi- 
tion are  developed  in  all  the  fetal  tissues  and  in  the  cavities  of  its  body. 
The  skin  is  distended,  translucent,  and  glistening.  It  crepitates  on 
pressure,  and  gas  escapes  from  incisions  carried  through  the  cuticle. 
The  trunk  and  extremities  are  largely  increased  in  volume,  and  their 
augmented  size  offers  an  obstacle  to  delivery  which  the  uterine  forces, 
probably  already  exhausted  by  prolonged  expulsive  efforts,  can  not 
overcome.  In  such  cases  the  bulk  of  the  child  should  be  diminished 
by  punctures  of  the  skin  to  allow  the  gases  to  escape,  and  when  the 
head  presents  it  should  be  extracted  with  the  cephalotribe.  Tractions 
upon  the  extremities  are  liable  to  be  followed  by  their  separation  from 
the  trunk. 

Tumors  developed  in  different  parts  of  the  fetal  trunk  may  disturb 
parturition.  The  most  frequent  site  for  these  tumors  is  the  sacral  and 
perineal  regions,  where  they  are  developed  between  the  sacrum,  the 
coccyx,  and  the  rectum.  Their  size  varies  from  that  of  a  small  wal- 
nut to  that  of  the  fetal  cranium  at  term,  and  it  may  even  exceed  these 
dimensions.  The  tumors  may  be  either  cystic,  fatty,  vascular,  carti- 
laginous, osseous,  or  carcinomatous.  So-called  cysto-hygromata  are 
also  frequently  observed  in  this  situation.  Similar  neoplasms  may  be 
located  in  the  axilla,  upon  the  pectoral  muscles,  and  in  the  anterior  or 

*  Whittaker,  Am.  Jour,  of  Obstet.,  vol.  iii,  1871,  p.  380;  Duncan,  Edinburgh 
Med.  Jour.,  August,  1870.  p.  163 ;  Hartmann,  Monatsschr.  f.  Geburtsk.,  Bd.  xxvii, 
1866.  p.  273;  Rose,  Ihid.,  Bd.  xxv,  1865,  p.  425  ;  Olshausen,  Arch.  f.  Gynaek.,  Bd. 
ii,  p.  280;  Kristaller,  Monatsschr.  f.  Geburtsk.,  Bd.  xxvu,  1866,  p.  165;  Heckek, 
Jhicl,  Bd.  xviii,  1861,  p.  373. 

f  Ahlfeld,  Arch.  f.  Gynaek.,  Bd.  iv,  p.  161. 
X  Rogers,  Am.  Jour,  of  Obstet.,  vol.  li,  p.  626. 

*  Schroeder,  Lehrbuch,  p.  634.  ||  Gervis,  Obstet.  Trans.,  vol.  v,  p.  284. 
^  Martin,  Monatsschr.  f.  Geburtsk.,  Bd.  xxvii,  1866,  p.  28. 

^  Voss,  o/A  cit.,  p.  26.  X  Herrgott,  op  cif.,  p.  266. 


556 


THE  PATHOLOGY  OP  LABOR. 


posterior  cervical  regions.  Spina  bifida,  when  accompanied  by  the 
formation  of  a  large  hydrorachitic  sac,  constitutes  another  form  of 
congenital  fetal  tumor,  and  is  most  frequently  observed  in  the  lumbo- 
sacral region.  Ectopia  of  the  abdominal  viscera,  hernias,  hydatid  cysts, 
and  encysted  neoplasms  of  the  abdominal  walls  sometimes  constitute 
tumors  sufficiently  extensive  to  impede  parturition.  We  may  also  cite 
anchylosis  of  the  fetal  joints,  adhesions  of  the  extremities  to  the  trunk 
or  to  one  another,  and  rigor  mortis,  as  rare  abnormalities  which  inter- 
fere with  that  pliability  of  the  child  requisite  for  its  adaptation  to  the 
parturient  canal,  and  finally,  adhesion  of  the  foetus  to  the  placenta  or  to 
the  uterine  parietes  as  causes  of  dystocia.* 

Diagnosis. — An  accurate  differential  diagnosis  between  these  varied 
morbid  conditions  can,  as  a  rule,  only  be  made  after  delivery.  If  en- 
largement of  the  trunk  be  present,  the  head  or  breech  is  born  without 
difficulty,  but,  the  progress  of  parturition  being  then  completely  ar- 
rested, an  investigation  easily  reveals  the  existence  of  an  abnormally 
large  trunk.  A  hvdrorachitic  sac  is  liable  to  be  mistaken  in  a  breech 
presentation  for  the  fetal  membranes.  Its  consistence  is,  however,  not 
altered  by  the  occurrence  of  uterine  contractions,  and  no  fetal  parts 
are  felt  beneath  the  membrane,  which  is  found  to  be  continuous  with 
the  fetal  cutaneous  surface. 

III.  Monstrosities. 

Dystocia  is  more  frequently  produced  by  double  monstrosities  than 
by  any  other  variety.  These  are  divided  by  Veit  f  into  three  principal 
classes,  characterized,  respectively,  by — 1.  Incomplete  double  forma- 
tion of  the  upper  or  of  the  lower  extremities ;  2.  Two  separate  bodies 
united  either  by  their  upper  or  by  their  lower  extremities;  3.  Two 
separate  bodies  attached  to  each  other  either  by  their  al)dominal  or  by 
their  dorsal  surfaces. 

Diagnosis. — The  differential  diagnosis  of  the  individual  deformities 
is  usually  impossible  in  the  earlier  stages  of  parturition.  Even  in  the 
succeeding  stages  it  is  difficult,  since  separate  twins  may  present  essen- 
tially the  same  phenomena.  The  diagnostician  will  derive  some  assist- 
ance from  the  facts  that  certain  women  seem  predisposed  to  the  devel- 
opment of  double  monsters,  and  that  certain  smaller  and  easily  recog- 
nizable deformities  of  the  extremities  (as  club-foot)  are  often  merely 
complications  cf  more  important  ones,  and  serve  to  indicate  the  exist- 
ence of  the  latter.  The  family  history  may  furnish  valuable  assistance, 
inasmuch  as  the  deformities  under  consideration  are  sometimes  heredi- 
tary. Double  monsters  are  most  frequently  observed  in  multiparae; 
but  this  fact  is  referred  by  Veit  J  to  the  relative  numerical  preponder- 

*  Whittaker,  Am.  Jour,  of  Obstet.,  vol.  iii,  1871,  p.  247. 

f  Veit,  Volkmann's  Samml.  klin.  Vortr.,  Volkmann,  1879,  Nos.  1G4,  165. 

+  Veit,  op.  cit.,  p.  1318. 


ABNORMALITIES  OF  THE  FCETUS.  557 

ance  of  the  former  over  primiparae.  "When  parturition  has  progressed 
sufficiently  to  allow  of  introduction  of  the  hand  within  the  uterus, 
should  the  necessities  of  the  case  call  for  this  measure,  the  diagnosis 
becomes  clear. 

Mechanism  of  Labor. — The  natural  forces  suffice,  according  to  the 
statistics  of  Playfair  and  Hohl,*  for  the  delivery  of  double  monsters  in 
more  than  fifty  per  cent  of  the  cases.  This  fact  may  be  attributed  to 
the  comparatively  small  dimensions  of  the  foetus  and  to  the  frequent 
occurrence  of  abortion  or  of  premature  delivery  in  cases  of  this  nature. 
The  course  of  parturition  in  a  case  of  the  first  variety  is  similar  to  that 
obtaining  when  the  head  of  a  single  foetus  is  of  unusually  large  di- 
mensions. The  second  variety  does  not  ordinarily  seriously  interfere 
with  delivery,  particularly  if  there  be  a  breech  presentation.  In  this 
case  the  bodies  pass  through  the  parturient  canal  simultaneously,  lying 
parallel  to  each  other.  One  head  then  passes  along  the  hollow  of  the 
sacrum  and  is  first  expelled,  while  the  other  is  retained  above  the  brim, 
its  neck  being  bent  into  close  apposition  to  the  pubes  until  after  the 
exjDulsion  of  its  fellow.  Should  there,  however,  be  a  disparity  be- 
tween the  lengths  of  the  necks,  both  the  heads  may  simultaneously 
j)ass  through  the  pelvic  canal.  When  they  reach  the  outlet,  the  head 
attached  to  the  longer  neck  is  expelled.  The  second  head  must  then 
be  expelled  with  the  neck  and  shoulders  of  the  former.  Under  these 
circumstances,  interference  on  the  part  of  the  obstetrician  is  usually 
required. 

Head  presentations  are  the  most  common  ones  in  cases  of  the  third 
variety,  and  the  course  of  parturition  is  as  follows :  The  head  of  one 
foetus  is  born,  that  of  the  other  being  detained  above  the  pelvic  brim. 
The  trunk  belonging  to  the  first  head  then  follows.  Xext  comes  the 
second  trunk ;  and,  finally,  the  head  belonging  to  the  latter.  Spon- 
taneous delivery,  when  it  occurs,  is  usually  eifected  in  this  manner. 
Head  presentations  of  the  first  variety,  i.  e.,  those  in  which  a  single 
trunk  possesses  two  heads,  usually  pursue  the  course  Just  described. 

Prognosis. — The  prognosis  for  the  child  is  very  unfavorable,  owing 
to  its  exiDulsion  in  an  undeveloped  condition  and  to  the  compression 
exerted  upon  it  during  labor.  The  prognosis  for  the  mother  is  favor- 
able because  of  the  usual  small  dimensions  of  the  foetus  and  of  the 
freedom  with  which  measures  for  the  reduction  of  its  volume  are  re- 
sorted to  in  view  of  its  probable  early  demise. 

An  acardlacus  is  a  monster  devoid  of  the  heart.  It  is  developed 
simultaneously  with  a  normal  foetus,  and  is  usually  born  after  the  lat- 
ter. Its  development,  as  already  explained,!  occurs  in  the  following 
manner :  The  balance  of  circulation  in  the  anastomosing  vascular  sys- 
tems of  twins  contained  in  a  single  chorion  (and  therefore  of  the  same 
sex)  becomes  disturbed,  and  the  pressure  in  one  system  so  preponder- 
*  Spiegelberg,  Lehrbuch,  p.  531.  f  Chapter  on  Multiple  Pregnancy. 


558 


THE  PATHOLOGY  OP  LABOR. 


ates  over  that  in  the  other  that  the  circulation  of  the  latter  is  reversed, 
and  its  hearts,  lungs,  and  body  atrophy.  It  now  receives  its  nutritive 
supplies  from  the  normal  foetus.  As  the  result  of  congestion  in  its 
umbilical  vein,  its  connective  tissue  often  undergoes  hypertrophy  and 
cedematous  infiltration.  The  same  cause  may  result  in  hydrocephalus 
or  in  the  development  of  a  monster  presently  to  be  described  as  an 


Fig.  220.— Author's  case  of  acardia. 

anencephalus.  The  most  common  variety  of  acardiacus  is  known  as 
the  acephalus,  or  headless  monster.  The  amorphus  is  an  acardiacus 
without  head  or  extremities.  It  is  of  rounded  form,  and  its  surface, 
though  ordinarily  smooth,  may  present  faintly  marked  tubercles,  which 
are  regarded  as  rudimentary  extremities.  Tlie  interior  of  the  amor- 
phus contains  a  rudimentary  intestinal  canal,  cystic  cavities,  muscles, 
and  vertebrae.      The  umbilical   cord  is  attached  indifferently  to   any 


i 


ABNORMALITIES  OF  THE   FOETUS.  559 

part  of  the  body.  The  rarest  form  of  the  acardiacus  is  the  acormiis, 
or  trunkless  monster.  It  consists  of  an  imperfectly  devekjped  head 
with  a  rudimentary  trunk.  Its  umbilical  cord  is  attached  to  the  cer- 
vical region. 

An  anencephalus  or  hemicephalus  is  a  monster  with  a  well-devel- 
oped trunk  and  a  rudimentary  head.  The  neck  is  short  and  the  head 
rests  directly  upon  the  shoulders,  which  are  so  unusually  broad  as  to 
constitute  an  impediment  to  delivery.  The  amount  of  amniotic  fluid 
is  ordinarily  large.  The  face  is  turned  upward  and  the  eyes  are 
prominent.  The  most  common  jjresentations  for  an  anencephalus  are 
the  transverse  and  the  breech.  Sometimes  the  face  or  the  exposed 
base  of  the  skull  presents.  In  such  a  case  the  diagnosis  may  be  made 
by  recognizing  the  sella  turcica  and  other  bony  prominences  of  the 
base.  Keflex  actions  may  be  produced  by  irritation  of  the  medulla,  as 
it  rests  exposed  upon  the  basilar  process  of  the  occipital  bone.*  This 
deformity  produces  obstruction  by  permitting  other  extremities  to  enter 
the  pelvic  cavity  simultaneously  with  the  diminutive  head,  and  by  the 
unusual  breadth  of  its  shoulders.  The  latter  are  more  readily  expelled 
when  the  parturient  canal  has  been  previously  dilated  by  the  passage 
of  the  breech. 

IV.  Shortness  of  the  CoRD.f 

Though  dystocia  from  shortness  of  the  cord  is  of  rare  occurrence, 
it  should  always  be  regarded  as  a  possible  source  of  delayed  labor. 
Shortness  of  the  cord  may  be  absolute,  as  in  cases  where  its  length 
does  not  exceed  a  few  inches ;  or  a  normal,  or  very  long  cord,  may,  by 
the  formation  of  coils  around  the  foetus,  become  taut  as  the  foetus  is 
expelled  from  the  uterus. 

In  the  preliminary  stage  of  labor  the  effect  of  shortness  of  the  cord 
is  sometimes  perceptible  in  the  irregular  heart-action  of  the  fcetus,  in 
the  recession  of  the  head  not  due  to  the  resistance  of  the  soft  parts 
during  the  intervals  between  the  pains,  and  in  an  interference  with  the 
mechanism  of  labor  as  characteristic  of  an  early  period.  In  the  second 
stage  the  effects  of  the  shortening  may  be  experienced  at  the  j^elvio 
outlet.  Usually,  however,  difficulty  is  not  encountered  until  after  the 
expulsion  of  the  head. 

As  the  result  of  the  tension  to  which  the  cord  is  subjected,  it 
stretches,  and,  as  Duncan  points  out,  some  gain  in  distance  from  child 
to  placenta  is  obtained  by  the  drawing  out  of  the  two  insertions,  the 
navel  and  abdominal  wall  on  the  one  hand,  and  the  placenta  and  uter- 
ine wall  on  the  other ;  or,  if  the  cord  encircles  the  child,  length  may 
be  gained  by  compression  of  the  encircled  parts.      Stretching  alone 

*  Herrgott,  op.  cit.,  p.  263. 

f  Matthews  Duncan,  Obstruction  owing  to  Shortness  of  the  Cord,  Obstet. 
Trans.,  1881,  p.  243;  Chautreuil,  Des  dispositions  des  cordens,  Paris,  1875. 


560  THE  PATHOLOGY  OF  LABOR. 

may  permit  natural  birth  to  take  place.  If  not,  the  continued  tension 
may  result  in  the  tearing  of  the  cord,  in  partial  inversion  of  the  uterus, 
or  in  the  separation  of  the  placenta.  According  to  Duncan,  the  cord 
yields  to  a  strain  equal  to  five  and  a  half  pounds  for  the  weakest,  and 
fifteen  pounds  for  the  strongest. 

AVhen  the  cord  becomes  taut  during  the  expulsion  of  the  foetus,  the 
anterior  surface  of  the  latter  rotates  forward  so  as  partially  to  undo  the 
encircling  and  diminish  the  tension.  In  the  completion  of  the  birth 
the  cord  lies  close  to  the  urethra,  and  forms  a  radius  around  which  the 
body  revolves,  a  movement  which  Duncan  aptly  compares  to  spontane- 
ous evolution  in  shoulder  presentations. 

Under  these  several  conditions  the  fetal  mortality  is  said  to  be  up- 
ward of  twenty  per  cent.  That  of  the  mother  is  much  less  serious. 
Aside  from  heemorrhages  due  to  placental  detachment,  and  rare  in- 
stances of  uterine  inversion,  the  most  important  consequences  are  those 
which  result  from  delayed  labor.  I  have  witnessed  the  following  case, 
which  terminated  fatally :  The  patient  was  a  primipara,  twenty-two 
years  of  age,  who,  after  five  days  of  ineffectual  labor,  entered  the 
Emergency  Hospital.  Her  temperature  was  103"5°  Fahr.  She  was  in 
great  agony.  The  external  genital  organs  were  inflamed.  The  fetal 
heart  had  ceased  to  beat,  and  meconium  escaped  from  the  vagina.  The 
head  could  be  seen  through  the  gaping  vulva.  After  giving  ether,  I 
applied  forceps,  but  met  with  more  resistance  than  I  had  anticipated. 
After  extracting  the  head,  on  passing  up  the  finger  I  found  the  cord 
tense,  and  coiled  a  number  of  times  around  the  child's  neck.  When 
about  to  sever  the  cord,  a  sudden  pain  was  followed  by  the  expulsion 
of  child,  cord,  and  placenta  together.  The  next  day  the  external 
genitals  became  gangrenous,  and  on  the  fifth  day  the  patient  iied  from 
a  slough  in  the  upper  portion  of  the  vagina,  which  communicated  Avith 
the  peritoneal  cavity,  and  had  evidently  been  the  result  of  the  long- 
continued  pressure. 

A  positive  diagnosis  can  only  be  made  when  the  labor  has  so  far 
advanced  that  the  cord  can  be  felt  with  the  finger.  The  treatment 
consists  in  loosening  the  coils,  where  it  is  possible,  or  in  severing  the 
cord,  if  accessible,  and  speedily  extracting  the  infant.  During  expul- 
sion the  rotation  of  the  child  forward  may  be  aided,  and  assistance 
may  be  rendered,  by  external  pressure  downward  upon  the  fundus  of 
the  uterus. 

V.  Transverse  Presextatioxs. 

In  so-called  transverse  presentations  the  axis  of  the  child  crosses 
obliquely  the  axis  of  the  uterus.  A  horizontal  position  of  the  foetus, 
with  both  extremities  occupying  nearly  the  same  level,  is  the  rare  ex- 
ception. Usually  the  child  lies  obliquely  with  the  head  resting  upon 
an  iliac  fossa.     When  the  uterus  contracts,  the  shoulder  is  usually 


ABNORMALITIES  OP  THE   PCETUS.  561 

pressed  down  into  the  lower  uterine  segment;  hence  shoulder  and 
transverse  presentations  are  frequently  employed  as  synonymous  ex- 
pressions. In  shoulder  presentations  prolapse  of  the  lower  arm  or  of 
the  cord  are  not  of  infrequent  occurrence. 

The  position  of  the  child  with  the  head  to  the  left,  as  the  more 
frequent  one,  is  termed  the  first  position ;  with  the  head  to  the  right, 
the  second  position.  According  as  the  back  of  the  child  is  directed 
forward  or  to  the  rear,  we  further  distinguish  dorso-anterior  and  dorso- 
posterior  positions.     The  dorso-anterior  position  is  the  usual  one. 

According  to  Churchill's  statistics,  the  frequency  of  transverse  pres- 
entations is  1 :  252,  Spiegelberg  found  it  1 :  180,  while  in  France  the 
combined  statistics  of  Depaul,  Dubois,  and  Pinard  show  a  frequency  of 
1:117  (Charpentier). 

The  causes  of  this  abnormality  are  to  be  found  in  the  absence  of 
the  conditions  which  contribute  to  the  fixation  of  the  cephalic  extrem- 
ity. Thus  a  predisposition  is  created  by  an  excess  of  amniotic  fluid,  by 
placenta  pr^evia,  by  multiparity,  by  premature  births,  by  death  of  the 
foetus,  and  by  uterine  and  pelvic  deformities. 

Diagnosis. — The  existence  of  a  transverse  presentation  can  usually 
be  ascertained  by  means  of  external  palpation.  Thus,  the  hard,  round 
head  can  be  mapped  out  in  most  cases  in  an  iliac  fossa,  and  the  soft 
breech  of  smaller  size  be  felt  at  a  higher  level  upon  the  opposite  side. 
Upon  vaginal  examination,  the  presenting  part  is  commonly  felt  high 
up  at  the  level  of  the  brim,  so  that  it  is  sometimes  necessary  to  intro- 
duce the  half  or  even  the  entire  hand  to  arrive  at  certainty  in  diagnosis. 
Great  care  should  be  exercised  in  passing  the  finger  through  the  cervix 
for  purpos9s  of  exploration,  as  it  is  especially  desirable  to  avoid  pre- 
mature rupture  of  the  membranes.  In  an  early  stage  of  labor  the 
vaginal  vault  is  flattened.  With  the  advance  of  the  first  stage  the 
shape  of  the  bag  of  waters  corresponds  to  the  resistance  offered  by  the 
cervical  canal.  In  multipara,  and  in  all  cases  where  softening  and 
dilatation  proceed  rapidly,  the  ordinary  globular  segment  may  form 
in  advance  of  the  presenting  part;  if  the  cervix  remains  rigid,  the 
membranes  usually  make  their  way  through  the  cervical  canal  as  an 
elongated  pouch,  a  condition  which  especially  favors  the  early  occur- 
rence of  rupture.  Sometimes  the  diagnosis  is  made  clear  by  the  pres- 
ence of  a  prolapsed  extremity  in  the  bag  of  waters.  After  rupture  of 
the  membranes,  the  shoulder  is  recognized  by  feeling  the  scapula  with 
its  spine,  the  arm-pit,  the  clavicle,  and  the  ribs,  and,  in  many  cases,  by 
means  of  a  prolapsed  upper  extremity. 

The  position  is  determined  by  the  direction  of  the  head  and  of  the 
back.  Often  these  can  be  made  out  by  external  palpation  alone  ;  by 
vaginal  examination,  the  relations  of  the  scapula  and  clavicle  to  the 
uterine  walls,  and  the  direction  of  the  arm-pit,  furnish  the  data  for  the 
formation  of  the  diagnosis.  If  the  arm  is  prolapsed,  it  may  be  drawn 
36 


562 


THE  PATHOLOGY   OF   LABOR, 


outside  the  vulva.  If  the  hand  then  be  turned  with  the  palm  upward, 
the  arm  is  always  of  the  same  name  as  the  side  of  the  mother  to  which 
the  thumb  is  turned.  If  the  presenting  arm  and  the  direction  of  the 
head  be  known,  the  position  of  the  back,  whether  to  the  front  or  rear, 
is  readily  deduced. 

Spontaneous  Version". 

The  term  spo7ifaneons  versmi  is  applied  to  the  process  by  which 
either  a  transverse  position  is  transformed  througli  Nature's  unaided 
eiforts  into  a  longitudinal  one,  or  to  that  by  which  a  normal  position 
is  either  partially  or  completely  reversed.  Spontaneous  version,  which 
occurs  during  pregnancy  as  a  very  frequent  physiological  phenomenon, 
is  observed  with  comparative  infrequency  during  labor.  It  may  be 
partial  or  complete,  according  as  the  presenting  member  is  displaced 
laterally  through  either  90°  or  180°,  may  occur  before  or  after  the 
rupture  of  the  membranes,  and  may  result  in  the  transformation  of  a 
transverse  position  into  either  a  head,  a  breech,  or  a  footling  presenta- 
tion. According  to  the  statistics  of  Hausemann,*  cases  of  spontaneous 
version  after  rupture  of  the  membranes  are  nearly  five  times  as  fre- 
quent as  those  occurring  before  their  rupture.  The  same  author  states 
that  the  head  presented  in  eighty  per  cent  of  the  cases  occurring  be- 
fore rupture  of  the  membranes,  and  the  breech  in  seventy-five  per  cent 
of  those  taking  place  after  the  occurrence  of  that  event.  Spiegelberg  f 
cites  two  cases  from  his  own  practice  in  whicli  tlierc  was  an  escape  of 
so-called  "false  waters,"  the  real  membranes  remaining  intact,  and 
attributes  the  occurrence  of  spontaneous  version  in  such  instances  to 
the  change  of  uterine  form  rendered  possible  by  the  evacuation  of  the 
false  waters. 

Etiology. — Among  the  conditions  predisposing  to  spontaneous  ver- 
sion is  the  uterine  atony  incident  to  repeated  deliveries.  About  two 
thirds  of  all  the  women  in  whom  spontaneous  version  occurs  are,  ac- 
cordingly, multiparag,J  and  their  average  age  is  thirty  years.  Spon- 
taneous version  often  recurs  during  several  consecutive  pregnancies  of 
the  same  individual.  It  is  more  apt  to  occur  during  deliveries  effected 
at  term  than  in  abortions  or  premature  deliveries.  A  living  foetus  is 
more  frequently  the  subject  of  spontaneous  version  than  a  dead  one, 
and  many  authors  attribute  an  important  agency  in  the  production  of 
the  altered  position  to  the  active  movements  of  the  child.  The  uterine 
contractions  are  necessarily  weak  in  cases  of  spontaneous  version  occur- 
ring before  the  rupture  of  the  membranes,  as  powerful  pains  would 
force  the  presenting  part  still  farther  into  the  dilated  os  and  fix  it  im- 
movably in  the  pelvic  brim.  On  the  other  hand,  the  contractions  of 
the  uterus  during  a  spontaneous  version  which  takes  place  after  the 

*  Hausemann,  Monatsschr.  f.  Geburtsk.,  Bd.  xxiii.  1864,  p.  SOfi. 

t  Spiegelberg,  Lfihrbuch,  p.  539.  %  Hausemann,  loc.  cit.,  p.  213. 


ABNORMALITIES  OF   THE   FCETUS.  563 

escape  of  the  amniotic  fluid  must  be  strong,  as  will  be  explained  in 
our  remarks  on  the  mechanism  of  the  process  in  question.  An  undi- 
lated  cervix,  powerful  contractions  of  the  uterine  fibers,  and  a  fully 
developed  child  are  essential  conditions  for  the  occurrence  of  spontane- 
ous version  after  rupture  of  the  membranes.  8ome  authors  consider 
the  presence  of  a  certain  amount  of  amniotic  fluid  indispensable  to 
the  occurrence  of  spontaneous  version  in  those  cases  taking  place  after 
rupture  of  the  membranes.  It  is  also  necessary  in  such  instances  that 
the  shoulder  or  other  presenting  part  be  freely  movable,  not  having 
yet  been  firmly  fixed  in  the  cervical  or  pelvic  canal. 

Mechanism  of  Partial  Version. 

1.  Before  Rupture  of  the  Memljranes. — In  this  case  the  shoulder 
usually  presents,  the  head  being  lower  than  the  breech.  The  os  is  only 
partly  dilated.  The  woman  having  assumed  a  position  upon  that  side 
of  her  body  toward  which  the  head  is  directed,  the  breech  tends  to 
descend  under  the  influence  of  gravitation,  while  the  head  is  thus  ap- 
proximated to  the  cervix.  The  contractions  of  the  uterine  muscular 
fibers  now  complete  the  version  by  exerting  pressure  ujjon  the  breech. 
When  the  uterus  has  once  regained  its  natural  shape,  the  normal  j^osi- 
tion  is  retained  by  the  foetus  until  the  completion  of  parturition.  In 
other  instances,  the  breech  being  lower  than  the  head,  the  same  mech- 
anism leads  to  a  breech  or  to  a  footling  presentation, 

2.  After  RujHure  of  tlte  Membranes. — In  this  variety  of  spontane- 
ous version  the  amniotic  fluid  has  partially  or  entirely  escaped,  allow- 
ing the  foetus  to  be  tightly  grasped  by  the  uterine  muscular  walls, 
which,  therefore,  labor  under  a  mechanical  disadvantage.  The  os  is 
only  partially  dilated.  The  pains  force  the  presenting  part  into  close 
contact  with  the  os  internum.  Owing  to  the  absence  of  an  equally 
distending  bag  of  waters,  the  os  does  not  dilate,  and  soon  assumes  a 
condition  of  tetanic  spasm,  during  which  it  can  be  felt  as  an  unyield- 
ing, cartilaginous  ring.  The  contractions  of  the  fibers  at  the  fundus 
uteri  having  now  become  more  forcible,  the  fetal  head  or  breech,  as 
the  case  may  be,  is  subjected  to  violent  pressure.  Inasmuch,  however, 
as  the  unyielding  os  prevents  any  progress  downward,  the  presenting 
part  is  displaced  laterally,  and  that  part  of  the  fcetus  which  previously 
occupied  the  fundus  is  forced  into  the  pelvic  entrance.  The  uterus 
next  regains  its  natural  form,  the  os  dilates,  and  delivery  is  accom- 
plished. 

Mechanism  of  Complete  Version. 

Cases  of  complete  version,  which  are  very  rare,  consist  in  the  trans- 
formation of  one  normal  longitudinal  presentation  into  the  diametrical- 
ly opposite  one,  the  part  originally  presenting  having  rotated  through 
180°,     The  mechanism  is  essentially  identical  with  that  just  described. 


5(54:  THE   PATHOLOGY   OF  LABOR. 

Version  of  this  variety  is  only  likely  to  occur  when  the  amount  of 
liquor  amnii  is  large  and  the  child  small,  so  that  it  is  freely  movable. 
Spontaneous  version  before  the  rupture  of  the  membranes  occupies 
only  half  the  time  required  for  its  accomiDlishment  after  their  rupture. 
Twenty-four  or  thirty  hours  are  often  necessary  for  the  completion  of 
the  latter  variety.  Delivery,  too,  is  accomplished  more  speedily  in 
cases  of  the  former  kind  when  version  has  once  occurred. 

Prognosis. — The  prognosis  for  both  mother  and  child  is  good  in 
spontaneous  version  before  rupture  of  the  membranes,  but  is  graver 
when  the  turning  occurs  after  that  event,  contrasting  unfavorably  with 
manual  version,  owing  to  the  fact  that  injurious  pressure  is  liable  to 
be  exerted  upon  the  prolapsed  cord. 

Labor  when  the  Presentation"   remains  Transverse. 

If  the  transverse  presentation  continues  after  rupture  of  the  mem- 
branes, the  entire  contents  of  the  amniotic  sac  escapes,  and  the  uter- 
ine walls  retract  down  closely  upon  the  foetus,  or  the  shoulder  is  pressed 
into  the  pelvic  cavity,  the  contraction-ring  recedes,  and  the  back  of  the 
child  is  forced  into  the  cervix  and  the  thinned  lower  uterine  segment. 
In  the  latter  case  danger  of  rupture  becomes  imminent.  Usually,  if  the 
malposition  of  the  child  is  not  corrected  by  art,  or  rupture  does  not 
occur,  the  rigid  uterine  walls  closely  compress  the  foetus,  and  the  mother 
in  the  end  dies  from  the  ensuing  exhaustion,  or  from  metritis,  from 
peritonitis,  or  from  septicaemia.  In  rare  cases,  however,  spontaneous 
birth  of  tJie  child  may  take  place  by  the  process  termed  evolution. 

Spontaneous  evolution  is  the  process  by  which  a  shoulder  presenta- 
tion is  transformed,  within  the  true  pelvis,  into  a  combined  breech 
and  shoulder  presentation,  and  spontaneous  delivery  is  then  effected. 
Since  this  may  be  accomplished  in  two  different  ways,  there  are  two 
corresponding  varieties  of  spontaneous  evolution.  The  first  variety 
was,  according  to  Leishman,*  described  by  Douglas,  of  Dublin,  as 
"  spontaneous  expulsion."  Dr.  Taylor  f  takes  exception  to  Leishman's 
statement,  and  affirms  that  the  term  spontaneous  evolution  was  ap- 
plied by  Douglas  to  the  mode  of  delivery  in  question.  The  second 
was  described  by  Roderer  as  "  birth  with  double  body "  ("  evolntio 
conduphcato  corjjore''^),  and  more  thoroughly  explained  by  Klein- 
wachter.J 

Etiology. — Various  conditions  contribute  to  the  facility  with  which 
this  process  is  accomplished  by  Nature.  The  most  important  are 
powerful  pains,  a  roomy  pelvis,  and  a  small  foetus.  Of  these  condi- 
tions, the  first  only  is  essential;  Grenser*  has  demonstrated  that  a 

*  Leishman,  a  System  of  Midwifery,  Philiulelj)hia,  1873,  p.  337. 
f  Taylor,  Am.  Jour,  of  Obstet..  July.  1881, 

;  Kleinwachter,  Arch.  f.  Gynaek..  Bd.  li,  p.  111. 

*  Grenser.  Jlunatsschr.  f.  Geburisk.,  Bd.  sxvii,  1866,  p.  445. 


ABNORMALITIES   OF  THE   FCETUS, 


565 


contracted  pelvis  is  not  an  insurmountable  obstacle  to  spontaneous 
evolution,  provided  the  conjugate  diameter  be  alone  shortened.  Nor 
is  small  size  of  the  fcBtus  essential  to  the  occurrence  of  the  process  in 
question.  Spiegelberg*  states  that  it  is  often  observed  in  cases  where 
the  foetuses  are  mature  and  well  developed.  Softness  and  compressi- 
bility of  the  child  naturally  favor  the  production  of  spontaneous  evo- 
lution, as  is  demonstrated  by  its  frequent  occurrence  when  the  jDroduct 
of  conception  has  undergone  maceration. 

Mechanism. — The  mechanism  of  the  former  and  more  ordinary 
variety  of  spontaneous  evolution  is  as  follows :  The  presenting  shoulder 
is  forced  into  the  depths  of  the  true  pelvis  by  the  violence  of  the  uter- 
ine contractions,  instead  of  being  diverted  laterally,  as  is  the  ease  in 
spontaneous  versions  and  becomes  firmly  fixed  beneath  the  symphysis, 
while  the  corresponding  arm  protrudes  through  the  vulva.     The  body 


Fig.  221.— Neglected  shoulder  presentation.    Section  through  frozen  corpse.    (Chiara.) 

of  the  fffitus  is  then  so  forcibly  flexed  that  the  breech  and  the  head  lie 
in  close  proximity  to  each  other.  The  former  is  in  contact  with  the 
sacro-iliac  synchondrosis,  while  the  latter  is  immovably  held  between 
the  breech  and  the  upper  border  of  the  symphysis.  The  neck  and 
shoulder,  which  rest  against  the  lower  border  of  the  symphysis,  now 
become  the  pivot  upon  which  the  foetus  rotates.  The  trunk  of  the 
foetus  is  driven  beyond  the  shoulder,  and  the  thorax,  breech,  and  legs 
are  born  in  the  order  named.  The  other  shoulder  then  follows,  and 
the  head  is  finally  expelled. 

The  mechanism  of  the  second  variety  of  spontaneous  evolution, 
designated  by  Roderer  "  evolutio  conduplicato  corpore^'"'  which  is  much 

*  Spiegelberg,  Lehrbuch,  p.  541. 


566 


THE  PATHOLOGY  OF  LABOR. 


rarer  than  the  former,  differs  from  it  in  some  essential  features.  It  is 
greatly  facilitated  by  softness  and  compressibility  of  the  child,  and 
therefore  occurs  predominantly  in  cases  of  macerated  foetus.     It  is 

rarely  observed  in  other  cases,  un- 
less the  foetus  be  unusually  small 
and  its  tissues  greatly  relaxed. 

The  shoulder  is  in  this  instance 
forced  downward  and  imprisoned 
beneath  the  symphysis  pubis,  as  in 
the  former  variety,  while  the  arm 
protrudes  from  the  vulva.  The 
trunk  having  been  enormously 
flexed,  the  head  and  thorax  simul- 
taneously enter  the  pelvic  cavity, 
the  former  being  deeply  imbedded 
in  the  latter.  The  second  arm  and 
shoulder  lie  between  the  breech 
and  thorax  on  the  one  hand,  and 
the  head  on  the  other.  The  pre- 
senting shoulder  having  been  ex- 
pelled, the  head  and  thorax  are 
born  together,  and  these  are  fol- 
lowed by  the  breech  and  the  legs. 

Prognosis.  —  The  prognosis  in 
spontaneous  evolution  is  good  for 
the  mother,  but  very  bad  for  the 
foetus,  since  only  immature  chil- 
dren are,  as  a  rule,  able  to  pass 
through  the  ordeal  of  delivery  by 
this  method  alive.  Kuhn,  how- 
ever, has  reported  a  case  of  a  child 
born  alive,  weighing  four  and  a 
half  pounds  and  measuring  seven- 
teen inches  in  length ;  and  Simon, 
according  to  Spiegelberg,  collected  one  hundred  and  twenty-five  cases 
in  which  fourteen  children  were  born  living.  Three  of  the  one  hun- 
dred and  twenty-five  mothers  died.  In  the  variety  of  spontaneous 
evolution  known  as  '-'■  evolutio  conduplicato  coiyore^''  which  occurs  in 
the  rule  in  small  or  macerated  children,  the  prognosis  is  especially 
unfavorable.  In  these  latter  cases  Dr.  Taylor*  recommends,  when 
the  perinaium  is  distended  by  the  doubled  body  of  the  child,  to  make 
lateral  incisions  to  the  extent  of  three  to  four  inches  at  the  vulva,  and 
thus  remove  the  obstacle  to  delivery  afforded  by  the  pehic  floor. 

*  Taylor,  Am,  Jour,  of  Obstet.,  July,  1881,  p,  532. 


Fig.  232.— Birth  with  doubled  body. 
vKleiuwachter.) 


ECLAMPSIA.  567 

CHAPTER  XXX. 

ECLA3IPSIA. 
Definition. — Clinical  history. — Prognosis,  pathology,  and  etiology. — Treatment. 

Eclampsia  is  the  term  applied  to  convulsions,  tonic  and  clonic  in 
character,  the  foundation  of  which  is  laid  in  processes  connected  with 
pregnancy,  labor,  and  childbed  {eclampsia  gravidarum,  parturientium, 
■vel piterperartim).  By  this  definition  it  is  intended  to  exclude  the  con- 
vulsions due  to  hysteria,  true  epilej)sy,  and  cerebral  lesions,  which  oc- 
currences in  pregnancy  are  to  be  regarded  simply  as  accidental  compli- 
cations. In  eclampsia  there  is  loss  of  consciousness  during  the  attacks, 
with  at  first  a  disturbance  of  the  intellectual  faculties  m  the  intervals, 
afterward  deepening  in  severe  cases  into  coma.  Before  entering  upon 
a  discussion  as  to  the  probable  nature  of  this  affection,  it  is  proper  to 
present  a  summary  of  its  clinical  manifestations. 

Clinical  His  tori/. — Eclampsia  is  fortunately  a  tolerably  rare  event. 
Its  estimated  frequency  is  in  about  the  j)roportion  of  once  in  five  hun- 
dred pregnancies.  The  total  number  of  deaths  from  this  cause  re- 
ported to  the  Board  of  Health  in  New  York  city,  in  the  nine  years 
from  1867  to  1875  inclusive,  was  408.  The  estimated  maximum  num- 
ber of  deliveries  during  that  period  was  284,000,  or  nearly  one  death  to 
seven  hundred  confinements.  The  entire  niimber  of  deaths  occurring 
in  pregnant  women  from  all  causes  during  the  same  period  was  3,342, 
making  the  proportion  of  those  from  eclampsia  as  one  to  eight.  In 
the  majority  of  cases,  though  not  invariably,  premonitory  symptoms 
announce  the  impending  outbreak.  Of  these  the  most  important  are 
headache,  often  limited  to  one  side,  vertigo,  loss  of  memory,  gloomy 
forebodings,  flashes  of  light  before  the  e3"es,  contracted  pupils,  ambly- 
opia, sometimes  amaurosis,  ringing  in  the  ears,  dyspepsia,  nausea,  vom- 
iting, dyspnoea,  oedema  of  the  face,  of  the  labia  majora,  and  of  the 
extremities,  and,  finally,  and  of  first  importance,  the  presence  of  albu- 
men and  of  casts  in  the  urine. 

The  attacks  resemble  those  of  ej)ilepsy,  the  cry  only  lacking.  When 
they  occur  during  labor,  the  first  convulsion  often  is  preceded  by  a 
short  calm,  in  which  the  patient  ceases  to  complain,  closes  her  eyes, 
and  seems  to  have  sunk  into  a  ]3eaceful  slumber.  This  deceitful  truce, 
which  should  always  excite  the  keen  attention  of  the  physician,  is  fol- 
lowed in  a  few  minutes  by  convulsive  movements  of  the  orbicularis 
oris  muscle,  giving  to  the  patient  a  smiling  aspect.  Suddenly  the  eye- 
lids open,  the  eyes  become  fixed,  and  the  pupils  contract.  Then,  in  a 
few  seconds,  the  eyelids  open  and  shut  rapidly,  the  eyes  move  from 
side  to  side  or  roll  upward,  while  the  pupils  dilate  and  lose  their  sensi- 
tiveness to  light.     Very  rapidly  the  convulsive   twitchmgs  extend  to 


568 


THE  PATHOLOGY  OF  LABOR. 


the  other  muscles  of  the  face,  the  mouth  opens  and  is  drawn  to  one 
side,  the  head  is  moved  from  shoulder  to  shoulder,  sometimes  with 
lightning-like  alternations.  Frequentl}^  for  the  first  two  or  three  con- 
vulsions, the  movements  of  the  extremities  are  limited  to  the  pronation 
and  supination  of  the  forearm  and  to  the  closing  of  tlie  fingers  upon 
the  thumb.  Afterward  the  arms,  crossed  upon  the  thorax,  pass  from 
flexion  to  extension  with  great  rapidity.  The  movements,  as  a  rule, 
are  more  pronounced  iu  the  upper  than  in  the  lower  extremities. 
Sometimes  the  latter  are  fixed  with  tetanic  rigidity,  while  at  others 
they  are  flexed  at  the  knee  and  then  drop  of  their  own  weight,  now 
upon  one  side,  now  upon  the  other. 

As  a  consequence  of  the  resulting  disturbances  in  the  circulation 
and  respiration,  the  carotids  pulsate  with  great  distinctness,  the  super- 
ficial veins  of  the  neck  swell,  the  conjunctivae  become  injected,  and 
the  face  is  c3'anosed ;  the  heart's  action  becomes  intermittent,  and  the 
breathing  irregular  and  stertorous. 

In  the  tonic  convulsions,  which  occur  intercurrently  with  clonic 
ones,  the  head  is  inclined  to  one  side,  the  mouth  is  drawn  in  the  same 
direction,  the  jaws  are  closed,  the  eyes  are  fixed,  opisthotonus  or  pleu- 
rosthotonus  develops,  the  pulse  becomes  small  and  intermittent,  the 
respiration  is  suspended,  tiie  body  becomes  covered  with  a  cold,  clannny 
sweat,  and  often  involuntary  micturition  or  defecation  takes  place. 
The  tetanic  condition,  after  lasting  from  fifteen  to  thirty  seconds, 
gradually  diminishes  in  intensity. 

As  the  convulsions  cease,  the  distortion  of  the  face  disappears,  the 
cyanosis  diminishes,  the  eyelids  droop,  the  mouth  opens,  and  frothy 
saliva,  tinged  with  blood,  escapes  from  the  mouth  and  nostrils.  Ster- 
torous respiration  marks  tlie  beginning  of  sopor.  At  first  the  patient, 
unless  the  attack  has  been  of  unusual  severity,  can  be  roused  when 
spoken  to.  The  depth  of  the  sopor  is  proportioned  to  the  violence 
and  frequency  of  the  attacks.  ^Yhen  the  convulsions  are  repeated,  the 
patient  in  the  intervals  can  no  longer  be  made  to  respond  to  inquiries, 
but  passes  into  a  state  of  complete  unconsciousness.  The  duration  of 
a  single  attack  rarely  exceeds  a  minute,  and  in  a  majority  of  cases  lasts 
from  ten  to  thirty  seconds.  On  account  of  the  implication  of  the  re- 
spiratory muscles,  attacks  of  long  duration  are  scarcely  compatible  with 
continued  existence  (Spiegelberg). 

After  a  single  seizure  the  sopor  usually  disappears  in  from  one  half 
to  two  hours,  and  seldom  persists  beyond  a  single  day.  The  number 
of  seizures  in  a  single  day  may,  however,  be  exceedingly  numerous. 
Thus,  seventy  convulsions  have  been  reported  by  Braun,*  eighty-one 
by  Brummerstedt,f  and  one  hundred  and  sixty  by  Depaul.J 

*  Braun,  Lehrbuch  der  gesaramt.  Gynaekologie,  p.  822. 
t  Brummerstedt,  Bericht,  etc.,  Rostock,  1866. 
X  Vide  Spiegelberg,  loc.  cit.,  p.  556. 


ECLAMPSIA,  569 

With  very  rare  exceptions — of  which,  however,  I  have  never  seen 
an  example — the  urine  after  the  convulsions  is  found  loaded  with  albu- 
men, and  contains  an  abundance  of  renal  ejiithelium,  often  in  a  state 
of  fatty  degeneration,  casts,  and  sometimes  blood-corpuscles.  In  all 
cases  of  exceptional  severity  the  urine  is  scant  or  absent  altogether. 

Terminations. — In  favorable  cases,  after  the  expulsion  of  the  ovum 
the  attacks  cease  or  diminish  in  frequency  and  intensity,  the  pulse  and 
respirations  become  quiet,  and  the  coma  passes  gradually  into  gentle 
slumber.  On  awakening,  the  patient  complains  of  headache  and  of 
impaired  memory,  and  possesses  no  recollection  of  the  perils  through 
which  she  has  passed.  Pains  are  felt  in  the  muscles,  and  in  the  tongue 
when  the  latter  has  been  injured  to  any  considerable  extent  by  the  teeth. 

But  even  after  consciousness  returns,  the  danger  is  still  not  ended. 
Eclampsia  predisposes  to  post-partum  haemorrhage  and  to  puerperal 
inflammations ;  or  it  may  leave  behind  hemiplegia,  amblyopia,  an  en- 
feebled mental  condition,  or  psychical  disturbances,  especially  mania, 
which,  however,  usually  terminates  spontaneously  in  the  course  of  the 
first  three  days. 

In  fatal  cases  death  results  from  carbonic-acid  poisoning,  due  to 
tetanus  of  the  respiratory  mu.scles  or  to  exhaustion  of  the  nervous  sys- 
tem. Bailly  relates  the  history  of  a  patient  who  died  of  asphyxia,  due 
to  swelling  of  the  tongue. 

Of  anatomical  lesions  found  in  post-mortem  examinations,  the  most 
constant  are  hyperemia,  more  often  an  ansemic  state,  fatty  degenera- 
tion, and  atrophy  of  the  kidneys.  The  latter  is  rare,  and  in  many  cases 
the  renal  changes  are  of  moderate  extent.  In  thirty-two  examinations, 
Lohlein  *  found  in  eight  dilatation  of  one  or  both  ureters  and  of  the 
pelves  of  the  kidneys.  The  same  author  likewise  has  demonstrated  the 
existence  of  enlargement  of  the  heart  (the  comparisons  were  instituted 
with  those  of  other  pregnant  women),  indicative  of  increased  arterial 
tension.     The  brain-lesions  were  in  most  instances  insignificant. 

Prognosis. — The  prognosis  is  always  serious.  In  Dohrn's  collec- 
tion of  747  cases  the  death-rate  reached  29  per  cent ;  in  104  cases  col- 
lected by  Hofmeier  f  in  Schroeder's  Clinic  the  mortality  was  33-4  per 
cent.  A  better  showing  is  made  by  Braun,J  who  was  able  to  report 
from  Vienna  in  ten  years,  from  1869  to  1878,  73  cases,  with  twenty 
deaths  (26  per  cent),  five  from  peritonitis  and  fifteen  from  Bright's 
disease  alone. 

The  earlier  the  convulsions  occur  in  labor,  the  more  unfavorable 
the  prognosis.  This  is  well  shown  by  the  statistics  of  Lohlein.  Thus, 
of  eighty-three  cases  where  the  first  convulsions  occurred  before  or 
during  the  first  stage  of  labor,  40*5  per  cent  of  the  patients  died.     Of 

*  Lohlein,  Bemerkungen  zur  Ekhimpsiefrage,  Ztschr.  f.  Geburtsh.  und  Gynaek., 
Bd.  iv,  Heft  1,  p.  89. 

f  Hofmeier,  loc.  cit.  |  Braun,  Lehrbuch  der  gcs.  Gynaek.,  p.  833. 


570  THE  PATHOLOGY  OF  LABOR. 

fifteen  cases  where  the  first  stage  was  completed,  but  one  patient  died. 
Eclampsia,  which  develops  first  in  childbed,  usually  pursues  a  favor- 
able course.  Ldhlein  reports  eight  cases,  with  one  death,  which,  how- 
ever, was  the  result  of  infection. 

The  longer  the  labor  the  more  difficult  the  delivery ;  the  deeper  the 
coma  and  the  greater  the  insufficiency  of  the  kidneys  the  more  de- 
pressing is  the  outlook. 

It  is  very  rare  for  the  convulsions  to  cease  previous  to  the  expulsion 
of  the  child.  According  to  C.  Braun,  after  delivery  in  thirty-seven  per 
cent  the  convulsions  cease  entirely,  in  thirty-one  per  cent  they  become 
feebler,  while  in  thirty-two  per  cent  they  continue  for  a  time  with  un- 
diminished severity.  In  childbed  it  is  of  favorable  import  when  copious 
diuresis  sets  in,  and  is  followed  by  the  disajDpearance  of  tlie  albumen 
and  of  the  oedema. 

As  regards  the  children  of  eclamptic  women,  it  is  estimated  that 
fully  one  half  are  born  dead,  a  result  probably  due  to  asphyxia  from 
the  accumulation  of  carbonic  acid  in  the  blood  of  the  mother.  As  the 
results  depend  upon  the  number  and  duration  of  the  attacks,  it  is 
evident  that  the  danger  is  greatly  lessened  after  the  completion  of  th^ 
first  stage  of  labor. 

Pathology  and  Etiology. — As  in  discussions  upon  eclampsia  it  is 
evident  that  the  treatment  advocated  by  physicians  is  governed  almost 
exclusively  by  theoretical  considerations,  it  becomes  of  the  utmost 
importance  to  place  before  the  student  an  exact  statement  of  known 
facts,  with  an  attempt  to  estimate  at  their  true  value  the  deductions 
which  various  observers  have  drawn  from  them. 

Now,  in  the  first  place,  in  reviewing  the  foregoiug  history  of  the 
disease,  we  are  brought  face  to  face  with  the  very  striking  coincidence 
in  the  vast  majority  of  cases  between  renal  insufficiency  and  the  con- 
vulsive seizures.  This  insufficiency  may  or  may  not  be  associated 
with  albuminuria,  though  the  two  go  jiretty  constantly  together.  The 
honor  of  first  drawing  attention  to  the  relations  between  albuminuria 
and  puerperal  convulsions  belongs  to  Dr.  John  C.  AV.  Lever,  who  re- 
ported in  Guy's  Hospital  Reports,  second  series,  1842,  fourteen  cases, 
in  ten  of  which  the  urine  was  examined.  Albumen  was  found  in 
greater  or  less  quantity  in  nine  cases ;  in  the  post-mortem  made  in 
the  tenth  case  the  death  was  discovered  to  have  been  due  to  acute 
memngitis.* 

These  observations  were  followed  by  others  from  British  physicians, 
among  whom  may  be  mentioned  Simpson,  Garrod,  Cormack,  and 
Eses;  and  in  France  treatises  upon  the  subject  Avere  iDublished  by 
Cohen  and  Delpech,  and  by  Devilliers  and  Eeguault. 

*  Vide  Tyson,  The  Causal  Lesions  of  Puerperal  Convulsions,  Philadelpliia,  1879. 
To  this  excellent  summary  I  desire  to  acknowledge  my  indebtedness  for  a  deal  of 
labor  saved,  as  regards  the  search  for  references. 


ECLAMPSIA.  571 

In  1851  Frerichs  pointed  out  clearly  the  close  resemblance  between 
the  convulsions  occurring  in  pregnancy  and  the  ur^emic  convulsions  of 
Bright's  disease.  After  reviewing  the  evidence  with  scientific  pre- 
cision, he  concluded  that  "  true  eclampsia  occurs  only  in  pregnant 
women  suffering  with  Bright's  disease,  and  it  bears  to  the  latter  the 
same  causal  relation  as  convulsions  and  coma  in  Bright's  disease  in 
general ;  it  is  the  result  of  the  uraemic  intoxication,  with  which  also 
in  its  mode  of  manifestation  it  agrees."  To  this  view  Braun,  in  the 
same  year,  and  Wieger,  in  1854,  brought  effective  support  by  the  pub- 
lication of  a  great  number  of  observations  confirmatory,  both  in  re- 
spect to  the  clinical  features  and  the  j^ost-mortem  appearances,  of  the 
uraemic  origin  of  puerperal  convulsions.  In  1857  Braun  published 
one  of  the  most  meritorious  treatises  upon  midwifery  to  be  found  in 
any  language.  In  this  work  the  new  doctrine  was  presented  with  so 
much  skill  and  clearness  that  since  then,  in  the  minds  of  the  great 
body  of  practitioners,  the  terms  eclampsia  and  uraemia  have  come  to  be 
regarded  as  synonymous. 

In  order  to  understand  the  present  position  of  the  question,  it  is 
necessary  to  review  the  objections  which  the  uremic  theory  has  had  to 
encounter.  Among  its  earliest  opj)onents  was  Seyfert,  of  Prague,  who 
occupying  the  vantage-ground  as  director  of  the  maternity  hospital  of 
that  place,  second  only  in  size  to  the  great  maternity  at  Vienna, 
furnished  the  clinical  counter-experiences  which  have  since  proved  the 
most  effective  weapons  in  the  hands  of  those  who  have  regarded  the 
new  doctrine  as  specious  and  heretical.  The  facts  which,  he  insisted, 
invalidated  the  claims  of  Frerichs  and  Braun  were  as  follows :  * 

1.  That  convulsions  may  occur  without  albuminuria. 

2.  That  the  albuminuria  is  in  many  cases  the  effect  and  not  the 
cause  of  the  convulsions. 

3.  That  in  many  fatal  cases  the  kidney-lesions  were  absent  or 
wholly  insignificant. 

4.  That  convulsions  are  rare  in  chronic  Bright's  disease  which  had 
existed  prior  to  pregnancy. 

5.  That  in  true  ursemia,  such  as  necessarily  is  produced  by  the 
sujjpressiou  of  urine  when,  in  uterine  cancer,  the  ureters  are  invaded, 
convulsions  do  not  occur. 

That,  in  the  main,  these  propositions  are  correct,  hardly  admits  of 
question.  But,  in  drawing  conclusions  from  these,  unnecessary  stress 
is  laid  upon  the  presence  or  absence  of  albumen  in  the  urinary  secre- 
tion. It  is  the  renal  insufficiency,  it  should  be  fixed  in  the  mind,  and 
not  the  albuminuria,  which  is  associated  with  convulsions.     The  mere 

*  As  T  hiive  copied  this  list  from  notes  taken  from  the  lectures  of  Seyfert, 
delivered  in  the  summer  session  of  18G5,  I  shall  not  consider  it  necessary  to  more 
than  incidentally  refer  to  the  corroborative  testimony  since  advanced  m  support  of 
their  validitv. 


5Y2  THE  PATHOLOGY  OF  LABOR. 

absence  of  albumen  from  the  urine  does  not  even  exclude  the  existence 
of  Bright's  disease.  Braun  is  careful  to  note  that  in  certain  cases  of 
fatal  eclampsia,  in  spite  of  the  absence  of  albuminuria,  the  post-mortem 
examination  revealed  amyloid  degeneration  of  the  kidneys  and  of  the 
heart-structures  ;  and,  again,  in  others,  of  atroi)hy  of  both  kidneys, 
where  the  dropsy,  and  the  albumen,  and  casts,  wliich  had  been  present 
earlier  in  pregnancy,  had  entirely  disappeared  at  the  moment  the  con- 
vulsions occurred.  Bailly  has  shown  that  not  rarely  albuminuria  in 
pregnant  women  may  disappear  for  several  hours  and  then  reappear 
once  more,  so  that  it  is  possible  for  an  examination  to  be  made  during 
the  short  period  when  the  urine  ceases  to  be  albuminous. 

On  the  other  hand,  chronic  nephritis  does  not  necessarily  imply  in- 
sufficiency of  the  renal  secretion.  Seyfert  reported  over  70  cases  where 
women  suffering  from  Bright's  disease  became  pregnant ;  only  two  of 
these  had  convulsions.  Every  observer  has  seen  similar  instances  of 
immunity.  Nephritis  in  pregnancy  brings  with  it  its  own  peculiar 
dangers.  Of  forty-six  cases,  chronic  in  character,  reported  by  Ilof- 
meier,  only  one  third  of  the  patients  had  eclampsia,  but  one  half  died. 
Including  acute  and  chronic  cases  together,  Braun  estinuitcs  that  only 
sixty  in  the  hundred  develop  uriemic  convulsions.  Ilofmeier  found, 
in  five  thousand  births  recorded  upon  the  history-books  of  the  Berlin 
Clinic  137  cases  of  nephritis  entered.  Of  these,  104  patients  only 
were  attacked  with  eclam])sia.  Professor  Bamberger*  reports  from 
autopsies  of  the  "  allgemeinen  Krankenhaus  "  in  twelve  years  2,430 
cases  of  Bright's  disease,  of  which  152  were  found  in  puerperal  and 
pregnant  v/^omen,  viz.,  80  acute  cases,  56  chronic  cases,  and  IG  cases  of 
atrophy ;  puerperal  eclampsia  was  recorded  in  23  instances. 

Flaischlen  f  found  in  examining  1,000  cases  of  pregnancy  that  albu- 
men was  present  in  twenty-six.  In  five  of  the  cases  the  patients  suf- 
fered from  catarrh  of  the  bladder,  and  in  two  chronic  nephritis  was 
diagnosed,  leaving  nineteen  per  thousand  in  whicli  albuminuria  was 
dependent  upon  pregnancy.  Of  537  cases  (205  primipars,  242  multi- 
paras) observed  during  labor  or  immediately  after  childbirth,  albumi- 
nuria was  present  in  93  women,  of  whom  73  were  primiparte  and  only 
20  were  multipara.  As  the  estimated  frequency  of  eclampsia  is  only  1 
to  500  cases  of  pregnancy,  the  mere  presence  of  albumen  is  not  neces- 
sarily of  grave  prognostic  importance. 

Lohlein  examined  the  records  of  thirty-two  autopsies  made  upon 
eclamptic  women,  and  found  in  eight,  or  in  twenty-five  j^er  cent  of  the 
entire  number,  that  dilatation  of  one  or  both  ureters  coexisted  with 
renal  disturbances.     He,  therefore,  pertinently  inquires  how  far  sim- 

*  Bamberger,  Ueber  Morbus  Brightii  und  seine  Beziehungen  zii  anderen  Krank- 
heiten,  Volkraann's  Saraml.  klin.  Vortr.,  No.  173,  p.  1541. 

t  Flaischlen,  Ueber  Schwangerschafts  und  Gcburtsineren.  Ztsehr.  f.  Geb.  und 
Gynaek.,  vol.  viii,  p.  358. 


ECLAMPSIA.  573 

plo  mechanical  obstruction  of  the  ureters  may  explain  the  apparent 
development  of  urEemic  manifestations  in  certain  cases  without  the 
warning  furnished  by  albumen  in  the  urine. 

Finally,  it  is  not  claimed  by  even  the  most  stalwart  champions  of 
the  urtemic  nature  of  eclampsia  that  the  convulsions  which  occur  dur- 
ing pregnancy  and  labor  are  invariably  the  result  of  the  same  cause. 
Thus,  Tyson  says  :  "  There  are  no  reasons  why  we  should  exclude  from 
the  causes  of  the  convulsions  in  the  puerperal  state  those  which  op- 
erate to  produce  convulsions  in  the  non-puerperal  condition."  So- 
called  cases  of  eclampsia  without  albuminuria,  i.  e.,  without  unemia, 
are  admitted  by  Braun  and  Spiegelberg,  and  referred  by  them  to  reflex 
stimulation  of  the  vaso-motor  and  convulsive  centers  (Krampfcentren). 
They  advocate,  however,  separating  them  off  into  a  class  by  them- 
selves under  the  title  of  acute  epilepsy,  or  eclamptiform  attacks,  a 
distinction  they  believe  warranted  by  their  rarity  and  their  benio-u  be- 
havior. 

The  objection  drawn  from  the  insignificance  of  the  kidney  changes, 
frequently  observed  in  post-mortem  examinations,  loses  most  of  its 
force  when  we  remember  that  in  a  large  proportion  of  cases  the  reten- 
tion of  excrementitious  materials  is  due  to  acute  suppression.  Thus, 
in  the  104  cases  of  eclampsia  reported  by  Hofmeier,  the  kidney  symp- 
toms developed  suddenly.  This  sudden  suspension  of  the  urinary  se- 
cretion can  only  result,  Spiegelberg*  argues,  from  disturbances  in  the 
renal  circulation.  A  rapidly  developed  affection  of  the  vessels  would 
leave  no  marked  post-mortem  traces,  and  would,  in  cases  of  recovery, 
disappear  as  quickly  as  it  had  come.  Were  the  kidney  troubles  due 
principally,  as  was  formerly  supposed,  to  pressure  of  the  gravid  uterus 
upon  the  renal  veins,  the  kidneys  should,  in.  post-mortem  examinations, 
exhibit  evidences  of  congestion ;  whereas,  usually  they  are,  on  the  con- 
trary, found  to  be  pale  and  anaemic.  Besides,  in  cases  of  pressure  from 
ovarian  and  pelvic  tumors  it  is  usually  the  ureters  and  not  the  veins 
which  are  implicated.  The  precise  nature  of  the  circulatory  changes 
is  not,  of  course,  definitely  known.  Spiegelberg  suggests  that  either 
the  walls  of  the  vessels  are  altered  in  such  a  manner  as  to  interfere 
with  the  process  of  diffusion,  or  that  a  reflex  contraction  of  the  vessels 
due  to  a  peripheral  stimulus  operates  to  cut  off  the  blood-supplies  to 
the  kidneys.  Frankenhaeuser,  having  demonstrated  a  direct  connec- 
tion by  means  of  the  sympathetic  nerve  between  the  ganglia  of  the 
kidneys  and  the  nerve-filaments  of  the  uterus,  had  likewise  suggested 
in  effect  that  the  albuminuria  of  pregnancy  was  due  not  to  pressure 
but  to  the  excitation  of  the  uterine  and  renal  nerve  plexuses. 

Cohnheim  supposes  that  the  renal  changes  of  pregnancy  are  due 
primarily  to  reflex  contraction  of  the  arterioles  of  the  kidney,  and  that 
the  albuminuria  and  the  epithelial  degeneration  are  secondary  phe- 
*  Spiegelberg,  Lehrbuch,  p.  561. 


p^^^  THE  PATHOLOGY   OF  LABOR. 

nomena.     Experimentally,  Litten  has  shown  that  similar  resnlts  follow 
upon  the  temporary  narrowing  of  the  renal  afferent  vessels  by  means 

of  ligatures.* 

The  statement  contained  in  the  fifth  proposition  relates  to  a  curi- 
ous fact,  which  has  since  received  confirmation  from  the  pathological 
investigations  of  Cornil  and  Kanvier.  In  a  very  large  proportion  of 
women  who  had  died  from  uterine  cancer  the  ureters  were  found  oc- 
cluded, with  attendant  dilatation  and  in  some  cases  with  hydrone- 
phrosis. Of  these  Cornil  wrote  :  "  With  these  obstacles  to  the  excretion 
of  urine  we  expected  uraemic  symptoms  to  be  manifested,  but  they  were 
not.  Although  the  attention  of  M.  Charcot  and  myself  was  fixed 
upon  this  point,  we  never  saw  either  the  epileptiform  convulsions  or  the 
coma  peculiar  to  uremic  poisoning." 

A  very  different  interest  attaches  itself,  however,  to  the  inquiry  as 
to  the  causes  of  the  outbreak  of  convulsions.  It  is  well  known  that 
not  every  case  of  nephritis,  or  even  of  kidney  insufficiency,  is  followed 
by  eclampsia,  though  convulsive  attacks  are  much  more  common  in 
the  uriBmia  of  pregnant  than  of  non-pregnant  women.  Frerichs  be- 
lieved he  had  found  the  secret  in  supposing  a  ferment  to  develop  in 
the  blood,  which  converted  the  urea  into  carbonate  of  ammonia.  In 
1870  Spiegelberg  reported  an  examination  of  the  blood  of  an  eclamp- 
tic woman  by  the  latest  methods,  and  demonstrated  the  presence  of 
ammonia  in  quantities  sufficient  to  give  color  to  the  supposition  of 
Frerichs ;  but,  subsequent  investigations  proving  negative,  he  con- 
cluded that  "  ammoniiemia  is  to  be  regarded  as  one  of  the  rarest  causes 
of  convulsions." 

An  apparently  much  more  scientific  explanation  was  afforded  by 
the  now  well-known  Traube-Rosenstein  theory,  which  maintained  that 
eclampsia  took  place  when,  in  persons  rendered  hydraemic  by  the  loss 
of  albumen,  the  aortic  pressure  was  suddenly  increased,  the  increased 
pressure  giving  rise  successively  to  oedema  of  the  brain,  then  to  sec- 
ondary compression  of  the  vessels,  and  finally  to  acute  anasmia.  An 
anaemic  condition  of  the  hemispheres  would,  it  was  predicted,  produce 
coma,  while  convulsions  would  ensue  if  the  condition  extended  to  the 
motor  centers. 

The  plausibility  of  this  hypothesis  was  increased  by  the  widespread 
acceptance  of  the  doctrine  taught  by  Andral  and  Gavarret,  that  the 
blood  of  all  pregnant  women  is  hydra3mic,  and  by  the  fact  that  the 
existence  of  increased  blood-pressure  during  the  pains  seemed  naturally 
to  account  for  the  frequency  of  convulsions  in  labor.  For  a  number 
of  years  after  the  announcement  of  the  Traube-Rosenstein  theory  it 
received  from  me  complete  acceptance;  but  my  faith  became  after- 
ward weakened  by  failing  to  find  at  post-mortem  examinations  the  an- 

*  OsTHOFF,  Beitrage  zur  Lehre  von  der  Eclampsie  und  Uraemie,  Sammlung  klin. 
Vortrage,  No.  206,  p.  1911. 


ECLAMPSIA.  5Y5 

ticipated  brain- changes,  viz.,  oedema,  anaemia,  and  flattening  of  the 
convohitions.  In  nineteen  examinations,  Lohlein  reported  these  alter- 
ations in  but  a  single  case.  In  his  Lehrbuch  der  Geburtshtilfe  Spiegel- 
berg  sums  up  the  objections  in  a  somewhat  contemptuous  fashion. 
First  he  asks  why,  if  the  pathogenetic  symptoms,  as  assumed,  are  in- 
variably present,  eclampsia  is  of  such  rare  occurrence,  and  in  what 
way  the  theory  in  question  affords  any  explanation  of  eclampsia  in 
pregnancy  and  childbed :  then  he  denies  that  eclamptic  women  are 
for  the  most  part  hydrgemic,  that  hydrgemia  and  arterial  pressure  are 
capable  of  inducing  cerebral  anaemia,  and  that  the  clinical  evidences 
afforded  by  the  pulse  and  pupils  are  those  produced  by  oedema. 

Angus  Macdonald  reported  in  1878  that  in  the  examination  of  the 
brain  in  eclamptic  persons  he  found  the  meninges  congested  and  the 
venous  sinuses  filled  with  blood,  while  at  the  same  time  there  Avas 
marked  ana3mia  in  the  deeper  layers  of  the  brain-structure.  The  ven- 
tricles, in  place  of  being  empty,  as  should  have  been  the  case  accord- 
ing to  the  Traube-Rosenstein  theory  of  oedematous  swelling,  were 
found  filled  with  serum.  In  place  of  the  doctrine  of  secondary  com- 
pression, he  expressed  his  belief  that  the  anaemia  resulted  from  arterial 
contraction  due  to  irritation  of  the  vaso-motor  centers  from  excremen- 
titious  principles  retained  in  the  circulation  by  the  insufficiency  of  the 
kidneys.  The  ingenious  theory  of  Macdonald,  however,  still  leaves 
unexplained  the  absence  of  convulsions  in  cases  where  the  tissues  are 
necessarily  loaded  with  urea,  and  their  occurrence  in  instances  where 
either  no  kidney  lesions  were  present,  or  where  the  kidney  and  cere- 
bral symptoms  were  coincident. 

The  disposition  to  ascribe  conAiilsions  to  cerebral  ansemia  is  based 
upon  the  experiments  of  Kussmaul  and  Tenner,  who  demonsti'ated 
that  convulsive  twitchings  might  be  produced  in  animals  by  tying  the 
carotids  or  by  opening  the  large  vessels  of  the  neck  and  allowing 
them  to  bleed  to  death.  It  is,  of  course,  anticipated  that  anaemia  due 
to  systole  of  the  arterioles  would  be  followed  by  the  same  results.  The 
phenomena  of  convulsions  are  twofold,  viz.,  loss  of  consciousness  and 
tonic  and  clonic  contractions.  Loss  of  consciousness  is  easily  to  be  ac- 
counted for  by  anaemia  of  the  hemispheres,  precisely  as  in  cases  of 
ordinary  syncope.  Convulsions  occur,  however,  when  the  brain  is  re- 
moved, if  only  the  pons  Varolii  and  the  medulla  oblongata  are  pre- 
served. Deiters  has  shown  that  the  motor  fibers  of  the  extremities 
and  the  trunk  have  their  first  central  terminations  in  the  pons.  Noth- 
nagel  *  has  proved  that  a  collection  of  ganglionic  cells  in  the  substance 
of  the  pons  furnishes  the  motor  center  from  which  the  convulsive  im- 
petus takes  its  departure.  According  to  Schroeder  van  der  Kolk,  the 
groups  of  gray  matter  for  the  cranial  nerves  are  situated  in  the  floor 

*  NoTHNAGEL,  Ileber  den  epileptischen  Anfall,  Volkraann's  Samral.  klin.  Vortr,, 
Xo.  39,  p.  313. 


576  THE  PATHOLOGY  OP  LABOR. 

of  the  fourtli  ventricle  and  in  tlie  substance  of  the  medulhi  oblongata. 
Any  influence  producing  contractions  of  the  arterioles  through  the 
vaso-motor  nerves  would  necessarily  produce  both  coma  and  convul- 
sions. As,  however,  convulsions  may  take  place  without  loss  of  con- 
sciousness, Nothnagel  concludes  that  the  same  cause  which  acts  indi- 
rectly through  the  vaso-motor  nerves  may  independently  set  in  action 
the  centers  of  muscular  movements. 

The  foregoing  considerations  have  led  writers  to  divide  convulsions 
into  two  classes,  viz.,  those  due  to  centric  causes  and  those  proceeding 
from  peripheral  irritation.  In  both,  cerebral  anaemia  plays  an  impor- 
tant part.  In  the  overwhelming  proportion  of  cases,  uremia  is  re- 
garded as  the  fountain  and  origin  of  the  evil,  the  term  urmnia  signify- 
ing, of  course,  the  action,  not  of  a  single  constituent  of  the  urine,  but 
of  all  the  excrementitious  principles,  combined  with  that  of  increased 
arterial  tension.  Whether,  in  exceptional  cases,  carbonate  of  ammonia 
or  cerebral  oedema  is  present,  is  a  matter  of  slight  moment.  The  role 
played  by  peripheral  irritation  is  not,  however,  to  be  overlooked. 
Without  ureemia,  though  rarely,  peripheral  irritation  can  provoke 
eclampsia.  In  uremic  cases  the  greater  proportion  develop  during 
labor.  In  Lohlein's  collection,  a  hundred  and  six  in  number,  ninety- 
three  of  the  patients  were  parturient.  Spiegelberg  has  frequently 
seen  convulsions  awakened  in  the  placental  period  by  the  mechanical 
irritation  of  the  uterus  during  the  employment  of  the  Crede  method 
of  expression. 

It  may  be  assumed  that  the  special  source  of  irritation  is  derived 
from  uterine  contractions,  which  the  observations  of  Braxton  Ilicks 
and  Frommel  show  are  not  confined  to  the  time  of  actual  labor,  ])ut 
occurs  spontaneously  during  the  entire  duration  of  j)regnancy,  aiul 
continue  through  the  retrograde  changes  of  tlie  childbed  period. 
Osthoff,*  indeed,  concludes  that  all  cases  of  eclampsia  have  equally  a 
•reflex  origin.  Thus,  an  irritation  jiroceeding  from  the  uterus  may  be 
transmitted  through  the  sympathetic  nerves  to  the  kidney  alone,  ex- 
citing contraction  of  the  arterioles  or,  when  sufficiently  intense,  it  may 
travel  upward  to  the  vaso-motor  center  in  the  medulla  oblongata,  and  be 
followed  by  contractions  of  the  arterioles  of  the  entire  body.  Evidence 
of  such  general  contraction  is  sujjplied  by  the  high  tension  and  slug- 
glishness  of  the  pulse,  while  the  resulting  anaemia  of  the  great  nerve- 
centers  furnishes  the  occasion  of  the  epileptic  attack. 

The  advantage  of  this  formula  as  a  working  hypothesis  is  that  it 
renders  intelligible  what  the  uraemic  theory  has  failed  to  do,  the  occur- 
rence of  eclampsia  without  kidney  lesion,  the  frequent  presence  of  kid- 
ney derangement  without  eclampsia,  and  the  special  gravity  of  eclamp- 
sia when  complicated  by  kidney   derangement.      In    questioning  the 

*  Osthoff,  Beitrage  zur  Lehre  von  der  Eclampsie  unci  Uraemie,  Volkmann'sehe 
Saramlung  klin.  Vortrage,  No.  29G. 


ECLAMPSIA.  577 

connection  between  uraemia  and  eclampsia,  the  danger  to  life  from  the 
retention  in  the  circulation  of  excrementitious  materials  is  in  no  wise 
disputed. 

Convulsions  occur  more  commonly  in  primiparge  than  in  multi- 
parfB,  especially  in  elderly  primiparas,  in  twin  pregnancies,  and  in 
women  with  contracted  pelves.  They  may  occur  epidemically  in  con- 
sequence of  atmospheric  conditions,  which  probably  interfere  with  the 
functions  of  the  skin,  and  thus  indirectly  increase  the  labor  thrown 
upon  the  kidneys. 

Treatment. — The  occasional  examination  of  the  urine  of  pregnant 
women  is  to  be  regarded  as  an  indispensable  precaution.  Faint  traces 
of  albumen  are  not  infrequently  found  in  the  urine  of  women  with 
harmless  catarrhal  affections  of  the  bladder.  Persistent  albuminuria 
calls  for  special  prophylactic  treatment ;  for,  though  convulsions  are 
not  to  be  regarded  as  the  necessary  consequence  of  nephritis,  the  pres- 
ence of  renal  disease  immensely  increases  the  danger  of  sudden  acute 
suppression.  Nephritis  is,  moreover,  apt  to  be  aggravated  by  the 
pregnant  state,  and  Hof  meier  has  shown  that  in  a  considerable  pro- 
portion of  the  cases  which  have  their  origin  in  pregnancy  the  kidney- 
lesions,  contrary  to  the  accepted  belief,  do  not  disappear  spontaneously 
after  parturition.  Flaischlen  has,  however,  recently  challenged  Hof- 
meier's  conclusions.  The  true  renal  lesion  of  pregnancy  he  regards  as 
due  to  anasmia  of  reflex  origin,  the  primary  consequence  of  which  is 
anatomically  an  alteration  in  the  epithelium  of  the  glomeruli,  and 
clinically  albumen  in  the  urine  without  sediment.  In  its  subsequent 
course  degenerative  changes  take  place  in  the  epithelium  of  the  cana- 
liculi,  and  great  quantities  of  albumen  with  cylinders  and  epithelia  are 
found  in  the  urine.  It  occurs  first  about  the  middle,  or,  more  fre- 
quently, toward  the  close  of  pregnancy.  As  distinguished  from  chronic 
nephritis,  in  which  the  specific  gravity  of  the  urine  is  low  and  the 
quantity  increased,  the  specific  gravity  is  high  and  the  quantity  dimin- 
ished. The  transition  of  this  form  into  chronic  nephritis  he  regards 
as  not  proved,  and  a  priori  improbable.* 

Every  precaution  should  be  taken,  therefore,  to  remove  from  albu- 
minuric patients  all  sources  of  mental  excitement,  to  ward  off  attacks 
of  indigestion,  and  to  defend  them  from  colds.  In  oedema  of  the  face, 
the  extremities,  and  the  labia  majora,  a  strict  milk  diet  should  be  en- 
joined, and  the  tincture  of  the  chloride  of  iron,  in  full  doses,  should 
be  given  at  least  four  times  a  day,  both  for  its  diuretic  and  for  its  hsem- 
atinic  properties,  and  likewise  to  improve  the  tomis  of  the  weakened 
vessels.  If  the  milk  diet  is  badly  supported  by  the  patient,  she  should 
be  instructed  to  drink  freely  of  the  natural  alkaline  waters  possessing 
mildly  diuretic  properties,  such  as  the  Vichy,  the  Selters,  the  Buffalo 
lithia-water,  the  Poland  water,  and  others  of  like  action.     To  remove 

*  Ztschr.  f.   Geburtsh.  unci  Gynaek.,  vol.  viii,  p.  354. 
37 


578  THE  PATHOLOGY  OF  LABOR. 

the  transuded  serum,  the  skin  should  be  compelled  to  aid  the  kidneys, 
either  by  means  of  the  Turkish  bath  or,  where  the  latter  is  not  avail- 
able, by  the  wet-jDack.  Mild  laxatives,  such  as  the  Friedrichshall,  the 
Hunyadi,  or  the  Saratoga  Avaters,  are  useful  in  constipation  of  the 
bowels. 

If  cerebral  symptoms  threaten  the  outbreak  of  convulsions,  the 
nervous  irritability  should  be  held  in  check  by  rectal  injections  of 
chloral  and  the  bromide  of  potassium  (thirty  grains  each),  and  a  hy- 
dragogue  cathartic  should,  be  promptly  administered.  Free  catharsis 
unloads  the  blood  of  urea,  diminishes  the  arterial  tension,  and  relaxes 
the  arterioles.  The  immediate  results  are  usually  in  the  highest  degree 
satisfactory.  The  pain  in  the  head,  the  sensory  disturbances,  the 
stomach  troubles  disappear,  and  the  patient  becomes  calm  or  sinks 
into  a  gentle  sleep.  Lohlein  recommends  placing  the  woman  in  the 
latero-prone  position,  in  order  to  diminish  as  much  as  possible  the 
pressure  upon  the  ureters  and  upon  the  renal  veins. 

So  far  writers  are  practically  unanimous.  Whatever  differences 
exist  between  them  relate  not  to  principles,  but  to  the  means  best 
adapted  to  accomplish  the  end  in  view.  When,  however,  in  sjiite  of 
palliative  measures  and  hygienic  precautions,  the  uraemic  symptoms 
have  steadily  progressed  until  the  central  nervous  system  has  become 
involved,  the  question  comes  uji  for  decision  whether  to  i:)ersevere  in  a 
plan  of  treatment  designed  merely  to  ward  off  impending  danger,  or 
whether  to  place  the  patient  without  delay  in  a  position  of  relative 
safety  by  the  induction  of  premature  labor.  The  weight  of  authority, 
it  seems  to  me,  is  favorable  to  procrastination,  the  interruption  of 
pregnancy  being  regarded  as  an  extreme  measure,  justifiable  only  in 
cases  of  utmost  peril.  But  premature  labor  with  the  indications  thus 
limited,  is  not  likely  to  save  many  lives.  My  own  convictions  are 
clear  that,  so  soon  as  grave  cerebral  symptons  develop,  the  period  of 
folded  hands  has  passed.  The  relief  to  be  obtained  from  chloral  and 
catharsis  is,  as  a  rule,  of  short  duration,  and  we  can  not  go  on  giv- 
ing chloral  and  cathartics  to  the  end  of  gestation,  nor  are  we  sure 
that  the  first  fortunate  results  can  be  reduplicated.  Moreover,  it  is 
necessary  to  take  cognizance  of  the  well-being  of  the  foetus,  which  is 
threatened  by  the  continued  circulation  of  urea  in  the  maternal  blood. 
The  induction  of  premature  labor  by  means  of  the  bougie,  aided,  if 
needful,  by  the  vaginal  douche  and  the  dilating  bags  of  Barnes,  is  at- 
tended with  but  moderate  risk  if  resorted  to  after  the  uraemic  symp- 
toms have  been  got  fairly  under  control ;  if  employed  as  a  last  re- 
source, where  other  therapeutical  measures  have  failed,  its  use  is  still 
justifiable,  though  it  then  partakes  rather  of  the  nature  of  a  forlorn 
hope. 

The  indications  for  treatment  during  the  outbreak  are  for  the  most 
part  the  same  as  laid  down  for  uremic  symptoms  unattended  by  con- 


ECLAMPSIA.  579 

vulsions,  viz.,  to  lower  the  arterial  tension,  to  diminish  to  the  fullest 
extent  practicable  the  irritation  of  the  vaso-motor  and  convulsive  cen- 
ters, and  to  restore  to  the  kidneys  their  normal  functions.  Spiegel- 
berg  claims  that  these  three  indications  are  most  completely  fulfilled  by 
venesection.  Professor  Fordyce  Barker  pleaded  for  the  restoration  of 
the  lancet  in  the  management  of  puerperal  convulsions,  insisting  upon 
the  unmistakable  clinical  evidences  favorable  to  its  employment.  In 
my  student-days  in  Paris,  at  the  Hopital  des  Cliniques,  where  the  an- 
cient usage  was  in  full  favor,  I  well  remember  my  first  feelings  of  alarm 
at  the  vigor  of  the  treatment  in  vogue ;  but,  after  carefully  watching 
the  cases  to  the  end,  I  was  led  to  conclude  that  the  claims  of  bleeding 
in  eclampsia  rested  upon  a  substantial  foundation. 

The  special  advantage  of  venesection  lies  in  the  rapidity  of  its  ac- 
tion ;  incidentally  it  favors  absorption  and  renders  the  patient  more 
susceptible  to  the  influence  of  other  remedies.  It  forms,  therefore, 
naturally  the  first  step  in  the  treatment  of  convulsions.  The  quantity 
of  blood  to  be  withdrawn  varies  from  eight  to  sixteen  ounces,  accord- 
ing to  the  vigor,  and,  to  some  extent,  according  to  the  size,  of  the  indi- 
vidual. 

In  the  May  number  of  the  American  Journal  of  Obstetrics,  1871,  Dr.  H. 
Fearn,  of  Brooklyn,  contributed  an  article  on  Veratrum  Viride  in  Large  Doses, 
as  a  Substitute  for  Bloodletting  in  Puerperal  Convulsions,  in  which  he  recom- 
mended the  tincture  of  veratrum  in  doses  varying  from  fifteen  minims  to  a  tea- 
spoonful,  repeated  every  five  or  ten  minutes  until  the  pulse  became  soft,  or 
vomiting  set  in.  For  several  hours  after  the  convulsions  are  arrested  he  ad- 
vises the  veratrum  to  be  administered  in  smaller  doses,  in  order  to  keep  the 
pulse  below  fifty  to  the  minute.  He  claims  that  the  large  doses  are  devoid  of 
danger  so  long  as  the  convulsions  continue.  According  to  Kenyon,*  who  has 
recently  contributed  two  cases  successfully  treated  by  veratrum,  "  the  drug  is 
quickly  absorbed,  and  enters  the  circulation  rapidly.  It  enters  the  vasa  vasorum, 
and  through  them  impairs  the  sensibility  of  the  vaso-motor  nerves,  the  blood- 
vessels thus  losing  their  tonicity  and  power  of  contraction  " — all  good  argu- 
ments for  its  use  in  convulsions  if  its  safety  can  be  established. 

After  bleeding,  narcotics  and  anaesthetics  should  he  resorted  to, 
with  a  view  of  preventing  the  renewal  of  the  convulsions.  Chloroform 
and  morphine  have  long  been  tested  in  practice,  and  have  sustained 
their  claims  to  professional  favor.  From  one  sixth  to  one  fourth  of  a 
grain  of  morphine  should  be  injected  hypodermically,  the  same  quantity 
to  be  repeated  in  an  hour  in  case  of  the  convulsions  returning.  Chlo- 
roform was  formerly  recommended  in  full  anaesthetic  doses,  so  as  to 
completely  paralyze  the  motor  centers.  As,  however,  experience  has 
shown  that  complete  and  prolonged  anaesthesia  is  in  itself  a  source  of 
danger,  it  is  advisable,  except  in  cases  where  labor  is  nearly  at  a  close, 

*  Kenyon,  Treatment  of  Convulsions  with  Veratrum  Viride,  N.  Y.  Med.  Jour., 
October,  1879,  p.  370. 


580  TPIE  PATHOLOGY  OF  LABOR. 

to  restrict  the  chloroform  to  the  pains,  and  to  the  restlessness  which 
is  often  the  preliminary  of  a  fresh  seizure. 

The  discovery  of  chloral  has  added  another  invaluable  agent  to  our 
list  of  available  antispasmodics  and  anfesthetics.  It  is  my  present 
practice,  after  beginning  with  chloroform,  to  administer  thirty  grains, 
each,  of  chloral  and  bromide  of  potassium  by  the  rectum,  and  to  sus- 
pend the  chloroform  so  soon  as  the  sedative  effects  of  the  latter  agents 
become  developed.  The  frequency  with  which  the  chloral  should  be 
given  depends  upon  the  frequency  and  violence  of  the  attacks.  A 
single  dose  will  sometimes  exercise  a  restraining  influence  for  hours, 
while  in  other  cases  in  the  course  of  an  hour  or  two  the  dose  will 
require  to  be  repeated.  As  a  subsidiary  measure,  with  a  view  to  the 
ultimate  relief  of  the  kidneys,  the  lower  bowel  should  be  cleared  out 
with  an  enema,  and  a  cathartic  (a  drop  of  croton-oil,  or  calomel  and 
Jalap  in  case  the  patient  is  able  to  swallow)  should  be  given  by  mouth. 

Breus*  warmly  recommends  the  use  of  the  hot  bath  as  a  prophy- 
lactic measure  in  the  renal  affections  of  pregnancy,  and  as  a  measure 
of  treatment  in  conjunction  with  chloral  during  the  eclamptic  attack. 
The  plan  he  recommends  consists  in  placing  the  patient  up  to  the 
neck  in  a  bath  of  a  temperature  at  first  of  about  102°,  which  should  be 
gradually  increased  to  110°  or  112°  Fahr.  The  bed  for  the  reception 
of  the  patient  should  be  spread  with  two  blankets  covered  by  a 
warmed  sheet.  After  a  half-hour  the  patient  should  be  removed  from 
the  bath,  wrapped  in  a  warm  sheet,  and  placed  upon  the  bed.  She 
should  theu  be  enveloped  in  the  blankets  with  only  the  face  free,  and 
two  more  blankets  should  be  laid  above  the  preceding.  In  a  few 
minutes  profuse  perspiration  sets  in,  and  should  be  maintained  for  from 
two  to  three  hours  The  covers  should  then  be  removed  gradually. 
Foi  thirst  he  gives  soda  or  other  sparkling  waters.  After  the  sweating, 
the  patients  ordinarily  sleep  a  few  hours,  when  they  feel  well.  A 
comatose  condition  is  no  contra-indication,  but  renders  the  procedure 
more  difficult.  The  diaphoresis  rapidly  diminishes  the  dropsical  symp- 
toms, and  is  followed  by  a  decided  diminution  in  the  amount  of  albu- 
men in  the  urine. 

As  convulsions  which  occur  after  the  advent  of  labor  have  a  tend- 
ency to  recur  so  long  as  the  labor  continues,  and  in  the  larger  propor- 
tion of  cases  cease  after  the  birth  of  the  child,  every  obstetrical  re- 
source compatible  with  the  safety  of  the  mother  should  be  employed 
to  hasten  delivery.  In  the  early  part  of  the  first  stage  the  pains,  if 
sluggish  should  be  stimulated  by  catheterization  of  the  uterus.  Braun 
advocates  rupturing  the  membranes,  as  he  claims  that  the  escape  of 
the  amniotic  fluid  often  diminishes  the  frequency  and  violence  of  the 
convulsions.      The  water-bags  of  Dr.  Barnes,  if  necessary,  should  be 

*  Breus,  Zur  Therapie  der  puerpcnileii  Eeliiiiipsie.  Arch.  f.  Gvnaek.,  vol.  xix, 
p.  219. 


POST-PARTUM   HEMORRHAGE   AND   RETAINED   PLACENTA.     581 

used  to  promote  the  dilatation  of  the  cervix.  Incisions  through  tlie 
border  of  the  os  externum  and  accouchement  force  are  unnecessary. 
After  the  first  stage  is  completed,  if  no  mechanical  disproportion  exists 
between  the  head  and  the  pelvis,  a  careful  attempt  to  extract  the  child 
with  forceps  should  be  made.  Every  precaution  should  be  used  to 
avoid  injuring  the  softs  parts.  Obstetrical  aid  is  only  warrantable 
where  it  can  be  employed  without  detriment  to  the  mother.  In  in- 
strumental cases,  with  the  head  high  in  the  pelvis,  I  have  had  every 
reason  to  feel  satisfied  with  the  Tarnier  forceps,  exchanging  it,  how- 
ever, for  one  of  English  pattern  so  soon  as  the  head  is  brought  to  the 
floor  of  the  pelvis. 

When  convulsions  occur  during  pregnancy,  the  question  as  to  the 
advisability  of  at  once  provoking  labor  is  by  no  means  settled.  The 
material  upon  which  to  form  an  opinion  is  limited,  as  in  most  cases 
labor-pains  occur  spontaneously  (as  a  consequence  of  the  convulsions). 
Where  medical  treatment  alone  is  employed  it  is  certain  that,  in  the 
absence  of  labor-j^ains,  a  certain  proportion  recover,  and  pregnancy 
may  go  on  to  comi)letion.  On  this  account  it  is  commonly  advised 
not  to  introduce  labor  as  a  complication  into  a  state  of  affairs  already 
sufficiently  dangerous  and  difficult  to  manage.  So  far  as  my  own 
experience  goes,  however,  the  practice  of  waiting  upon  Nature  has 
proved  uniformly  disastrous,  while  the  induction  of  labor  has  furnished 
me  with  a  certain  proportion  of  recoveries.  Braun  declares  he  has 
known  but  one  patient  to  recover  between  the  fourth  and  sixth  months 
of  pregnancy  except  where  abortion  had  taken  place.  The  question  is 
one,  however,  concerning  which  there  exists  a  reasonable  degree  of 
doubt,  and  which  can  not  be  settled  by  the  hap-hazard  experiences  of 
individuals. 

In  the  treatment  of  convulsions  during  the  childbed  period  the 
agents  used  should  be  opium,  chloral,  veratrum,  or  digitalis.  Chloro- 
form and  venesection  should  be  employed  with  extreme  caution,  if, 
indeed,  they  are  ever  entitled  to  confidence  at  that  time. 


CHAPTER  XXXI. 

POST-PARTUM  HEMORRHAGE  AND  RETAINED  PLACENTA. 

Normal  agencies  for  checking  haemorrhage. — Disturbances  of  contractility,  of  re- 
tractility, of  thrombus  formation. — Treatment. — Method  of  securing  contrac- 
tion and  retraction. — Treatment  of  cerebral  anjemia. — Retained  placenta. 

The  haemorrhages  which  occur  immediately  after  the  birth  of  the 
child  may  have  their  origin  in  the  uterus,  the  vagina,  or  the  vulva. 
It  is  customary,  however,  to  consider  those  which  spring  from  lacera- 


gg2  THE  PATHOLOGY  OF  LABOR. 

tions  in  a  chapter  by  themselves,  and  to  apply  the  term  post-partum  to 
those  hemorrhages  only  which  arise  from  the  placental  site. 

Unlike  other  grave  complications  of  childbirth,  ^jos^^ar^iow  haem- 
orrhage is  not  an  uncommon  event.  It  may  follow  the  simplest  of 
labors,  and,  in  case  of  an  unprepared  physician,  it  may  carry  his  patient 
in  a  few  moments  to  the  brink  of  death.-  It  is  impossible  to  conceive 
a  tragedy  more  terrible  than  this.  Occurring,  as  the  accident  does, 
suddeiily,  without  warning,  in  the  period  of  joy  that  follows  the  birth  of 
a  living  child,  the  sudden  shifting  of  the  scene  becomes  appalling.  If 
the  mother  dies  at  such  a  time,  the  luckless  attendant  who  stands  at 
her  bedside,  a  nerveless  spectator,  need  never  expect  forgiveness ;  nor 
can  he  shield  himself  behind  the  recorded  ill-successes  of  others. 
Every  competent  accoucheur  knows  in  his  own  heart  that  he  has  no 
right  to  shirk  his  personal  responsibility  in  cases  of  fatal  jjost-jjartuni 
hsemorrhage,  or  to  meanly  throw  the  blame  upon  Providence. 

The  treatment  of  post-partum  haemorrhage  is  one  of  the  most  sat- 
isfactory departments  of  obstetrical  practice.  In  no  other  emergency 
is  the  saving  of  life  so  little  dependent  upon  chance,  and  so  much  upon 
intelligent  human  intervention.  Successful  treatment  is,  however,  less 
the  result  of  a .  familiarity  with  the  various  procedures  extolled  by 
writers,  than  of  a  correct  understanding  of  the  mechanism  by  means 
of  whicli  the  arrest  of  the  ha?morrhage  is  to  be  effected. 

Normal  Agencies  for  checking  HsBmorrhage.— In  normal  cases  the 
flow  which  follows  the  detachment  of  the  placenta  is  of  brief  duration. 
The  torn  arterial  twigs  retract  spontaneously,  the  patulous  mouths  of 
the  veins  become  plugged  with  fibrinous  clots,  while  the  so-called  ve- 
nous sinuses,  which  are  simply  channels  lined  with  endothelium,  with- 
out valves  or  walls,  become  bent,  flattened,  and  obliterated  under  the 
compression  exerted  by  the  muscular  structures  of  the  uterus. 

The  first  requisite  against  ha?morrhage  is  the  maintenance  of  firm 
uniform  contraction  of  the  uterus.  The  contractions,  which  persist 
with  lessened  force  after  the  birth  of  the  child,  during  their  continu- 
ance alone  suffice  to  prevent  haemorrhage  from  the  placental  site.  The 
two  diagrams  borrowed  from  Professor  Breisky  serve  to  illustrate  the 
mechanism  by  which  this  is  effected.  In  the  transition  from  a  to  h 
the  uterus,  which  shortly  before  harbored  the  entire  ovum,  becomes 
reduced  to  a  body  not  larger  than  the  two  fists.  But  the  duration  of 
the  contractions  is  short,  with  an  ever-increasing  interval  between 
them.  If  their  cessation  were  followed  by  the  return  of  the  uterus 
from  h  to  a,  the  blood  would  once  more  rush  into  the  sinuses,  the 
mouth  of  the  veins  would  open,  the  thrombi  would  be  washed  out  by 
the  pressure  brought  to  bear  upon  them,  and  flooding  would  of  neces- 
sity ensue.  That  this  does  not  take  place  is  owing  to  the  same  force 
which  in  labor  keeps  the  uterus  closed  upon  its  contents  during  the 
descent  of  the  foetus— viz.,  tonic  retraction. 


POST-PARTUM   HEMORRHAGE  AND  RETAINED   PLACENTA.    583 

The  tonic  retraction  of  the  uterus  is  in  part  the  consequence  of 
shortening  of  the  muscuUir  fibers,  and  in  part  of  tlieir  rearrangement, 
a  tliickening  of  the  uterine  walls  resulting,  as  the  cell-elements,  in  place 
of  standing  end  to  end,  assume  a  position  more  nearly  parallel  to  one 


Fig.  223. 


another.  Retraction  is  a  permanent  acquisition  of  the  uterus,  and 
alone  suffices  to  prevent  the  occurrence  of  haemorrhage.  The  differ- 
ence between  it  and  contraction  is  exhibited  by  the  difference  in  the 
consistence  of  the  liost-partum  uterus  during  and  between  the  pains. 
The  contracted  uterus  is  hard  and  firm  like  a  billiard-ball,  while  the 
retracted  organ  is  relatively  soft  and  relaxed.  The  two  properties, 
though  distinct,  are  not,  however,  independent  of  one  another.  When- 
ever the  contractions  are  good,  the  retraction  is  well  marked  also. 
Whatever  diminishes  the  contractile  powers  of  the  uterus  is  followed 
.by  a  corresponding  falling  off  as  regards  its  retraction. 

In  cases  where  the  muscular  structures  of  the  uterus  fulfill  their 
normal  functions,  the  formation  of  thrombi  is  of  subordinate  impor- 
tance as  a  means  of  arresting  haemorrhage.  Confined  to  the  adherent 
portion  of  the  decidua  serotina,  they  impart  an  uneven  surface  to  the 
placental  site.  Thrombi  which  extend  to  the  intermuscular  veins  are 
pathological.  It  is  only  when  the  uterus  is  flabby,  and  the  muscular 
action  is  in  default,  that  the  thrombi  exercise  any  marked  influence  in 
the  control  of  haemorrhage,  and  even  then  they  bear  so  close  a  rela- 
tionship to  puerperal  thrombosis  as  to  approach  dangerously  near  to 
the  confines  of  pathology. 

The  causes  of  post-partum  haemorrhage  are  to  be  sought  for  in  dis- 
turbances of  the  mechanism  by  which  haemorrhage  is  normally  pre- 
vented. 

Disturbances  of  Contractility. — Contractions  of  the  uterus  may  fail 


gg^  TtlE   PATHOLOGY   OF  LABOR. 

from  lowering  of  the  muscular  irritability.  Atony  follows  most  fre- 
quently exhausting  labor,  artificial  deliveries,  rapid  evacuation  of  the 
uterus,  especially  in  multiparse,  where  the  failure  to  contract  has  often 
the  significance  of  a  prolonged  pause,  excessive  distention  (hydram- 
nios,  twins),  profuse  haemorrhages,  collapse,  nervous  depression,  and 
severe  general  ailments. 

Again,  in  other  cases,  the  functional  disturbance  may  proceed  from 
some  abnormal  condition  of  the  muscular  fiber.  Thus,  the  defects  of 
contractility  may  spring  from  incomplete  development,  as  in  anoma- 
lies of  formation,  in  textural  changes  due  to  some  antecedent  disease 
or  puerperal  condition,  especially  as  to  the  result  of  many  previous 
confinements,  or  finally  from  inflammatory  infiltrations  having  their 
source  in  the  bruising  of  the  lower  uterine  segment  during  labor. 

The  contractions  of  the  uterus  may  be  mechanically  interfered 
with  over  limited  areas  by  retained  portions  of  the  placenta  and  of  the 
membranes,  by  peritoneal  adhesions,  by  tumors  in  the  walls  of  the 
uterus  or  in  the  uterine  appendages,  or  by  a  distended  bladder  or 
rectum. 

Disturbances  of  Retractility.— AVe  have  already  seen  that  the  tonus 
of  the  muscular  fibers  is  lowered,  and  that  their  rearrangement  is  in- 
complete, whenever  the  uterine  contractions  are  in  default.  At  the 
same  time  the  retraction  of  the  uterus  may  be  directly  hindered  by 
mechanical  causes,  especially  by  those  which,  like  the  placenta,  the 
■membranes,  or  coagula  of  blood,  when  retained  in  the  uterine  cavity, 
prevent,  in  spite  of  continued  contractions,  a  sufficient  closure  of  the 
veins. 

Disturbances  in  Thrombus  Formation. — The  disturbances  whicli 
interfere  with  the  formation  of  thrombi  occur  for  the  most  part  in 
those  cases  in  which,  owing  to  the  defective  action  of  the  muscular 
structures,  the  blood-stream  arrives  at  the  mouths  of  the  vessels  with 
unchecked  rapidity.  As  a  consequence,  coagulation  does  not  take 
place,  or  the  coagula  are  of  soft  consistence,  and  ofter  but  feeble  resist- 
ance to  any  sudden  increase  of  blood-pressure,  or  become  mechanically 
detached  by  restless  movements  on  the  part  of  the  patient,  or  by  strain  • 
ing  with  the  abdominal  muscles. 

Outlying  Causes  of  Post-partum  Haemorrliage.— The  remote  causes 
of  post-partum  haemorrhage — i  e.,  those  not  immediately  connected 
with  the  uterus — all  act  by  indirectly  interfering  with  either  the  con- 
tractility or  the  tonus  of  the  muscular  fiber,  or  with  the  thrombus  for- 
mation. This  they  do  by  influences  exerted  either  through  the  nerv- 
ous system  or  through  the  circulation.  Thus,  the  muscular  irrita- 
bility may  be  impaired  by  general  debility,  by  wasting  diseases,  from 
impoverishment  of  the  blood  due  to  suffering  and  muscular  effort,  from 
psychical  impressions,  and  from  the  external  influences  of  heat  and 
vitiated  air.     The  normal  tonus  of  the  uterine  muscles  may  be  over- 


POST-PARTUM  HEMORRHAGE  AND   RETAINED   PLACENTA.     585 

come,  and  the  formation  of  thrombi  disturbed,  by  any  condition  of  the 
circuhitory  system  associated  with  increased  pressure  in  the  venous  or 
arterial  trunks.  The  pressure  in  the  uterine  veins  may  be  augmented 
by  the  patient's  getting  up  suddenly  in  bed,  by  acts  such  as  coughing, 
laughing,  sneezing,  vomiting,  and  defecation,  in  which  the  abdominal 
muscles  are  called  into  play,  and  by  all  the  conditions  which  pro- 
duce chronic  congestion  of  the  pelvic  organs.  Increase  of  arterial 
tension  as  a  cause  of  haemorrhage  is  rare.  Breisky  mentions  a  case 
where,  in  a  multipara  without  valvular  heart-disease,  the  cause  of  the 
haemorrhage  was  apparently  due  to  intense  palpitation  of  the  heart 
associated  with  the  hard,  incompressible  pulse  indicative  of  arterial 
fullness.* 

Treatment. — It  is  not  necessary  to  dwell  upon  prophylactic  meas- 
ures. As  has  been  shown  in  the  survey  of  the  causes  of  post-partum 
hcemorrhage,  they  comprise  everything  that  has  been  said  concerning 
the  proper  management  of  labor. 

Methods  of  securing  Uterine  Contractions. — It  is  my  own  practice, 
and  one  I  would  urge  upon  others,  to  make  provision  in  the  simplest 
of  cases  against  the  possible  occurrence  of  hajmorrhage.  In  the  be- 
ginning of  the  second  stage,  I  examine  my  Davidson  syringe  to  make 
sure  that  the  valves  are  in  good  working  order.  I  then  direct  a  small 
table  to  be  set  by  the  bedside  of  my  patient,  and  place  upon  it  a  bowl 
containing  pieces  of  ice  of  about  the  size  of  a  hen's-egg,  brandy,  sul- 
phuric ether,  neutral  perchloride  of  iron,  carbolic  acid,  ergot,  a  solu- 
tion of  morphia,  a  can  of  iodoform  gauze,  and  a  hypodermic  syringe 
filled  with  a  fluid  extract  of  ergot  or  two  grains  of  ergotin  in  solution. 
Within  easy  reach  I  likewise  have  placed  a  pitcher  of  hot  water, 
another  of  cold  water,  an  empty  basin  containing  the  Davidson,  or, 
still  better,  a  fountain  syringe,  and  a  bed-pan.  All  this  requires  but  a 
few  moments'  time,  and  it  is  of  no  mean  advantage  to  feel,  in  case 
haemorrhage  follows  the  birth  of  the  child,  that  all  the  appliances  for 
prompt  action  are  in  order  and  close  at  hand. 

If  hemorrhage  takes  place,  in  spite  of  the  fact  that  the  uterus  has 
been  carefully  guarded  by  external  pressure  during  the  period  of  de- 
livery, draw  the  pillows  from  under  the  head  of  the  patient,  direct  the 
nurse  to  open  the  windows,  and  ijiject  the  ergot  contained  in  the  hypo- 
dermic syringe  into  the  outer  surface  of  the  thigh.  Ergot  by  the 
mouth  acts  too  slowly  to  prove  of  service  in  the  face  of  a  great  emer- 
gency; besides,  in  many  patients  ergot  by  the  mouth  excites  nausea, 
and  is  not  absorbed  by  the  stomach  ;  hypodermically  its  action  is,  as  a 

*  The  foregoing  description  is  little  more  than  a  transcript  of  the  principles 
enunciated  in  Breisky's  clinical  lecture,  Ueber  die  Behandlung  der  puerperalen 
Blutungen  (Volkmann's  Samml.  klin.  Vortr.,  No.  14,  1871).  I  have  found  them 
of  the  utmost  service  to  me  in  practice  during  the  ten  years  past,  and  believe  with 
Breisky  that  they  furnish  the  key  to  successful  prophylaxis  and  treatment. 


586 


THE  PATHOLOGY  OF  LABOR. 


rule,  rai^idly  developed.  Then  introduce  the  hand  into  the  uterus.  If 
a  full  bladder  interferes,  draw  off  the  urine  with  a  catheter. 

The  introduction  of  the  hand  into  the  uterus  I  believe  to  be  a 
matter  of  the  utmost  importance.  When  combined  with  external 
pressure  it  stimulates  the  uterus  to  contract.  The  placenta,  if  ad- 
herent, should  be  detached  with  the  tips  of  the  fingers ;  if  loose  within 
the  uterine  cavity,  it  should  be  withdrawn  slowly,  taking  care  to  re- 
move the  membranes  entire.  Bits  of  placenta  or  strips  of  membrane 
should  be  carefully  scraped  from  the  uterus,  remembering  that  this  is 
most  easily  effected  during  the  contraction  of  the  organ.  Even  if  the 
placenta  and  membranes  are  expelled  apparently  entire,  it  is  still  de- 
sirable to  pass  the  hand  into  the  uterus  to  clear  out  clots,  and  to  make 
sure  that  no  part  of  the  ovum  has  been  left  behind.  Once  I  lost  a 
hospital  patient  by  neglecting  this  rule.  The  hemorrhage  was  checked 
by  compression,  and  upon  careful  inspection  of  the  placenta  and  mem- 
branes I  convinced  myself  that  everything  had  come  away.  The  pa- 
tient died  on  the  eighth  day,  of  se^jticaemia.  The  autopsy  revealed 
the  presence  of  a  small  placenta  siiccenturiata,  of  the  existence  of 
which,  aside  from  the  haemorrhage,  there  had  not  been  the  slightest 
indication. 

So  soon  as  the  uterus  has  been  emptied  of  everything  capable  of 
preventing  contraction  and  retraction  from  taking  place,  withdraw  the 


Fig.  234.— Bimanual  compression  of  uterus.    (Breisky.) 

hand  into  the  vagina,  and,  with  the  index  and  middle  fingers  in  the 
posterior  cul-de-sac,  press  the  cervix  forward  toward  the  body  of  the 
uterus.  With  the  external  hand  grasp  the  uterus  through  the  abdomi- 
nal walls,  compress  it  firmly  and  push  it  downward  toward  the  pelvis  and 
forward  against  the  pubic  bone.  By  this  manoeuvre  the  cervix  is  closed, 
the  uterine  walls  are  brought  into  contact  with  one  another,  and  con- 


POST-PARTUM   HEMORRHAGE  AND  RETAINED  PLACENTA.     587 

tractions  are  stimulated  by  the  direct  irritation  of  the  large  cervical 
ganglion  and  by  the  kneading  of  the  fundus.  Breisky  states  that  in 
many  cases  it  is  j^ossible  to  combine  compression  of  the  aorta  with  the 
foregoing  maniijulation. 

If  bimanual  compression  fails  to  speedily  secure  contractions,  with- 
out removing  the  internal  hand,  pieces  of  ice  may  be  slipped  into  the 
vagina,. and  thence  pushed  upward  into  the  uterine  cavity.  With  rare 
exceptions  the  uterus  responds  at  once  to  the  stimulus  of  cold  applied 
to  its  inner  surface.  Should  it  not  do  so,  however,  the  bed-pan  should 
be  placed  under  the  hips,  and  boiled  water  of  about  112"  Fahr.  should 
be  injected  into  the  uterus,  care  being  taken  to  expel  previously  all  air 
from  the  tube  of  the  syringe.  The  injection  should  be  made  slowly 
and  without  force,  allowing  the  fluid  to  escape  joari  passu  with  its 
introduction. 

The  most  important  factor  in  the  arrest  of  haemorrhage  unques- 
tionably consists  in  acting  promjitly  upon  the  first  signal  of  danger. 
If  through  lack  of  preparation  profuse  haemorrhage  should  occur,  the 
overcoming  of  the  resulting  atony  may  tax  to  the  utmost  the  re- 
sources of  the  attendant.  As  an  effective  remedy  against  this  condi- 
tion the  per-salts  of  iron  added  to  the  intra-uterine  douche  still  enjoys 
professional  favor.  It  is,  however,  many  years  since  I  have  found  it 
necessary  to  resort  to  their  use.  This  I  consider  fortunate,  for,  though 
there  is  abundant  testimony  as  to  the  efficacy  of  the  per-salts  of  iron  in 
post-pa rfum  haemorrhage,  the  arrest  of  the  flow  appears,  in  some  cases 
at  least,  to  have  been  achieved  at  too  dear  a  price.  Barnes  refers  the 
haemostatic  effect  of  the  iron — 1.  To  its  direct  action  in  coagulating 
the  blood  in  the  mouths  of  the  vessels ;  3.  To  its  action  as  a  powerful 
astringent  on  the  inner  membrane  of  the  uterus,  whereby  the  surface 
becomes  corrugated  and  the  mouths  of  the  vessels  are  coustringed ;  3. 
To  the  fact  that  it  often  provokes  some  amount  of  contractile  action  of 
the  muscular  wall.  Trask,  in  recommending  the  substitution  of  tinct- 
ure of  iodine  for  the  solution  of  the  perchloride  of  iron,  maintains  that 
it  is  the  third  mode  of  action  that  should  be  placed  first  in  the  order  of 
importance.  This  corresponds  with  my  own  experience.  In  two  cases 
Avhere  Monsel's  solution  was  used  the  uterus  contracted  promptly,  and 
the  injection  was  followed  by  no  disturbing  effects.  In  the  third  the 
uterus  remained  large  and  flaccid,  notwithstanding  the  haemorrhage 
was  arrested.  For  two  days  the  patient  did  well;  on  the  third  the 
lochia  became  excessively  offensive,  the  respirations  stertorous,  and  the 
pupils  dilated  ;  general  paralysis  ensued,  and  death  followed  within 
twenty-four  hours  of  the  attack.  Although  no  autopsy  was  made,  it 
was  clear  to  me  at  the  time  that  the  coagulation  had  followed  the  ves- 
sels to  the  substance  of  the  uterus,  and  that  the  fatal  result  was  due 
to  the  absorption  of  septic  material  by  the  large,  soft  thrombi,  which, 
by  their  disintegration,  became  the  means  of  conveying  infection  to 


588 


THE  PATHOLOGY  OF  LABOR. 


the  remoter  portions  of  the  organism.  Barnes  formerly  used  the  per^ 
chloride  of  iron  after  preliminary  removal  of  the  clots,  in  the  propor- 
tion of  one  of  iron  to  three  of  water.  Most  German  authorities  rec- 
ommend the  iron  in  a  much  more  dilated  form,  and  using  it  in  no 
fixed  proportion,  but  simply  to  pour  the  iron,  following  Seyfert's  pre- 
scription, into  the  water  until  the  latter  assumes  a  deep  wine-color.  In 
his  later  writings  Barnes  seems  to  regard  a  mixture  of  one  part  of  per- 
chloride  to  ten  or  twelve  of  watBr  as  adequate. 

Wallace  *  praises  vinegar  as  a  certain  and  safe  remedy  for  post-jxtr- 
tum  haemorrhage :  "  I  pour  a  few  tablespoonfuls  into  a  vessel,"  he 
says,  "  dip  into  it  some  clean  rag  or  a  clean  pocket-handkerchief.  I 
then  carry  the  saturated  rag  with  my  hand  into  the  cavity  of  the  ute- 
rus, and  squeeze  it ;  the  effect  of  the  vinegar  flowing  over  the  sides  of 
the  cavity  of  the  uterus  and  the  vagina  is  magical.  The  relaxed  and 
flabby  uterine  muscle  instantly  responds.  The  organ  assumes  what  I 
will  term  its  gizzard-like  feel,  shrinking  down  upon  and  compressing 
the  operating  hand,  and  in  the  vast  majority  of  cases  the  ha?morrhage 
ceases  instantly.  Should  one  aj^plication  fail  to  secure  a  sufficient  con- 
traction, the  rag  can  be  withdrawn,  and  a  second  or  even  a  third  can 
be  made,  until  the  uterus  shall  contract  sufficiently  to  stop  the  flow  of 
blood." 

Probably  the  farad aic  current  is  a  most  efficient  agent  in  securing 
contractions  of  the  uterus,  but,  unlike  vinegar  and  hot  water,  a  bat- 
tery is  rarely  on  hand  when  needed.  An  olive-shaped  bulb  electrode 
should  be  introduced  into  the  uterus,  and  the  other  pole,  a  flat  disk, 
pressed  upon  the  fundus ;  or  both  poles  may  be  applied  directly  over 
the  uterus  through  the  abdominal  walls. 

I  have  in  a  number  of  instances  seen  Dr.  I.  E.  Taylor  succeed  in 
instantaneously  causing  the  uterus  to  contract  by  slapjiing  the  lower 
part  of  the  abdomen  smartly  with  a  wetted  towel. 

Compression  of  the  aorta  through  the  abdominal  walls  is  capable 
of  rendering  temporary  service.  The  method  has  been  objected  to  on 
theoretical  grounds :  first,  because  the  compression  is  brought  to  bear 
equally  upon  the  vena  cava  as  upon  the  aorta ;  and,  second,  because 
the  pressure  does  not  cut  off  the  blood  which  goes  to  the  uterus 
through  tlie  aortic  uterine  arteries.  As  a  clinical  fact,  however,  it  is 
indisputable  that  the  pressure  does,  temporarily  at  least,  check  the 
hasmorrhage,  a  result  attributed  by  Frankenhaeuser  to  the  simulta- 
neous stimulation  of  the  aortic  uterine  plexus,  as  that  portion  of  the 
sympathetic  nerve  is  termed  which  overlies  the  large  vessels  of  the 
trunk  situated  in  the  lumbar  region. 

The  application  of  ice  to  the  abdomen,  or  allowing  a  stream  of  cold 
water  to  fall  from  a  height  upon  the  hypogastrium,  however  efficacious 
they  may  prove  as  means  of  arresting  hemorrhage,  are  open  to  the 
*  Trans.  Am.  Gynaecol.  Soc,  vol.  iii. 


POST-PARTUM   HEMORRHAGE  AXD   RETAINED   PLACENTA.     589 

grave  objection  that  they  add  to  ah*eady  existing  shock  and  to  the 
prostration  produced  by  the  loss  of  blood. 

Methods  of  securing  Uterine  Eetraction. — Uterine  contractions 
afford  only  a  temporary  safeguard  against  hemorrhage.  It  is  uterine 
retraction  that  prevents  recurrence.  At  first  the  hand  furnishes  the 
most  available  means  of  exercising  external  compression.  It  likewise 
possesses  the  advantage  of  being  an  intelligent  instrument,  capable  of 
conveying  to  the  accoucheur  instant  warning  of  any  tendency  to  relax- 
ation. But,  even  after  retraction  is  secured,  its  maintenance  should 
not  be  left  to  chance.  Before  leaving  his  patient,  the  physician  should 
provide  some  means  of  subjecting  the  uterus  to  sustained  and  equable 
pressure.  The  usual  method  consists  in  surrounding  the  anteverted 
organ  with  folded  napkins  or  rolled  stockings,  and  then  applying  a 
bandage  tightly  to  the  abdomen  to  keep  them  in  position.  Unless 
skillfully  executed,  this  method  accomplishes  little  more  than  to  dis- 
locate the  uterus  laterally.  I  have  been  in  the  habit  of  using  a  round 
bag  of  rubber  covered  with  brown  muslin,  which  I  i:)artial]y  fill  with 
cold  water,  and  apply  over  the  uterus.  The  dry  cold  is  of  value  as  a 
means  of  exciting  contraction,  while  the  hydrostatic  pressure  is  evenly 
distributed  over  the  fundus  of  the  uterus,  and  helps  to  fix  it  in  the 
median  line.  A  reliable  compress  may  be  improvised  in  any  house- 
hold by  partially  filling  a  sack  with  moistened  sand  or  common  salt. 

More  recently  Diihrsseu  *  has  advocated  the  packing  of  the  uterine 
cavity  with  iodoform  gauze.  The  method  he  pursues  is  as  follows : 
When  the  uterus  does  not  respond  to  kneading  and  an  ergotin  injection, 
he  first,  with  the  patient  placed  crosswise  in  bed,  washes  out  the  vagina 
and  uterus  with  a  three-per-cent  solution  of  carbolic  acid,  then  passes  the 
fingers  into  the  uterus  to  make  sure  that  it  is  empty,  and  finally,  with 
the  cervix  drawn  to  the  vulva  with  volsella  forceps,  or  under  the  guid- 
ance of  two  fingers  passed  to  the  cervix,  a  strijD  of  iodoform  gauze  is 
pushed  by  means  of  uterine  forceps  to  the  fundus  and  cavity  of  the 
uterus  until  the  latter  is  completely  filled.  The  result  is  said  to  be  the 
immediate  arrest  of  hemorrhage  due  to  the  intra-uterine  comj^ression, 
and  the  contraction  of  the  uterine  muscle.  Dr.  Polk  has  tried  the 
method  in  the  Bellevue  Hospital,  and  has  been  favorably  impressed 
with  its  efficacy.  Diihrssen  advises  that  the  packing  be  extended 
from  the  uterus  to  the  vagina  to  control  hemorrhages  due  to  lacera- 
tions, but  in  tears  of  the  cervix  as  well  as  in  those  about  the  vulva,  the 
practitioner  will  find  the  suture  the  safest,  the  simplest,  and  the  most 
certain  haemostatic. 

Treatment  of  Anaemia.— In  consequence  of  excessive  loss  of  blood, 
the  surface  of  the  body  becomes  blanched,  cold,  and  bedewed  with 
clammy  perspiration ;  a  feeling  of  muscular  prostration  is  experienced, 

*  DuHRSSEX,  Ueber  die  Behandlung  der  Blutungen  post-partum,  Volkmann'sche 
Sammhing,  No.  C-IT. 


590 


THE  PATHOLOGY  OF   LABOR. 


with  distress  in  the  prrecordial  region  ;  thirst  follows  the  rapid  absorp- 
tion of  serum  from  the  parenchymatous  organs  to  make  good  the  loss 
of  fluid  in  the  blood-vessels ;  the  pulse  becomes  small  and  frequent, 
the  respiration  rapid,  and  air-hunger  is  developed  as  the  result  of  the 
deficient  amount  of  oxygen  carried  by  the  attenuated  blood-stream  to 
the  tissues  and  the  medulla  oblongata.  AVith  these  general  symptoms 
are  associated  special  ones  due  to  disturbances  of  the  nerve-centers,  as 
restless  movements  from  side  to  side,  yawning,  vomiting,  perversions 
of  the  special  senses,  fainting,  and  convulsions. 

Now,  it  is  to  these  latter  symptoms,  indicative  of  intense  cerebral 
anaemia,  and  directly  imperiling  the  life  of  the  patient,  that  treatment 
requires  to  be  especially  addressed.  The  pillows  should  be  withdrawn 
from  the  head,  the  foot  of  the  bed  should  be  raised,  hot  bottles  should 
be  placed  to  the  extremities,  and  warm  cloths  to  the  head ;  if  syncope 
occurs,  the  abdominal  aorta  should  be  compressed  to  reserve  the  entire 
blood-mass  for  the  upper  portion  of  the  trunk  and  the  brain ;  cerebral 
congestion  should  be  promoted  by  opiates  (thirty  drops  of  laudanum  by 
the  mouth,  or  ten  minims  of  Magendie's  solution  hypodermically  in- 
jected), and  the  flagging  heart  should  be  stimulated  by  hypodermic 
injections  of  sulphuric  ether,  brandy,  or  whisky.  The  syringe  should 
be  filled  with  the  agent  chosen,  and  the  injection  should  be  made  deep 
into  the  subcutaneous  cellular  tissue  on  the  outer  ])art  of  the  thigh. 
The  effect  upon  the  circulation  is  almost  instantly  manifested.  Ex- 
cept in  cases  whicli  have  passed  beyond  all  possiliility  of  recovery,  the 
pulse  reappears  at  the  wrist,  often,  however,  to  fade  away  again  in  a 
few  minutes.  The  stimulant  injections  in  many  cases  require  to-  be  re- 
peated a  number  of  times  before  the  circulation  becomes  re-established. 
So  long,  however,  as  there  is  a  perceptible  response  to  the  stimulus,  tlie 
case  is  never  to  be  regarded  as  hopeless. 

Dr.  Gaspar  Griswold  has  employed  successfully  in  a  number  of 
cases,  where  the  heart  had  apparently  beat  for  the  last  time,  intra- 
venous injections  of  ammonia,  using  for  the  purpose  a  five-per-cent 
solution  (the  officinal  solution  diluted  with  equal  parts  of  water),  and 
injecting  with  a  hypodermic  syringe  from  fifteen  drops  to  a  half- 
drachm  into  one  of  the  superficial  veins  of  the  forearm. 

In  the  collapse  resulting  from  excessive  hemorrhage,  the  restoration 
of  blood  to  the  circulation  by  transfusion  is  theoretically  the  rational 
mode  of  treatment.  In  practice,  however,  the  difficulties  of  the  tech- 
niqiie,  the  hesitation  of  bystanders  to  furnish  the  required  blood,  com- 
bined with  the  somewhat  unsatisfactory  outcome  of  transfusion  experi- 
ments, are  all  obstacles  to  its  employment.  More  favorable  results 
have,  however,  been  obtained  by  substituting  weak  solutions  of  common 
salt  for  blood  in  cases  where  transfusion  has  been'^ndicated.  Although 
-the  saline  solution  can  not  replace  blood,  it  has  been  proved  to  be  a 
harmless  agent,  and  capable  of  performing  a  useful  part  by  so  far  restor- 


POST-PARTUM   HAEMORRHAGE   AND   RETAINED   PLACENTA.     59 1 

ing  the  meclianicul  conditions  of  circulation  as  to  furnish  a  basis  for 
analeptic  treatment.  The  transfusion  apparatus  needed  is  of  the  sim- 
plest character,  viz. :  A  glass  funnel,  a  piece  of  rubber  tubing  eighteen 
inches  in  length,  and  a  canula  of  glass  or  metal  for  introduction  into 
the  vein  selected.  The  strength  of  the  solution  employed  should  not 
exceed  five  to  six  grains  to  the  pint  (0-6  per  cent  to  0-75  per  cent). 
Before  ojierating  the  instruments,  the  utensils,  and  the  solution  should 
be  thoroughly  sterilized.  The  temperature  of  the  solution  should  be 
from  100°-103°.  The  amount  injected  varies  from  a  pint  to  a  quart. 
The  transfusion  should  take  place  slowly,  under  a  pressure  of  from  ten 
to  eighteen  inches.  The  ordinary  time  required  is  from  fifteen  to 
thirty  minutes.  When  the  process  is  ended  a  double  ligature  should 
be  applied  to  the  vein,  and  the  wound  should  be  covered  with  an  anti- 
septic dressing.* 

After  the  heart's  action  has  once  been  established,  the  efforts  of  the 
physician  should  next  be  directed  to  the  filling  of  the  emptied  vessels 
and  the  restoration  of  the  arterial  tension.  With  the  restoration  of  the 
cardiac  pulsations,  the  absorption  from  the  stomach  is  very  active  and 
rapid.  To  avoid  vomiting,  however,  it  is  necessary  that  fluids  adminis- 
tered by  the  mouth  should  be  given  in  small  quantities  and  at  brief 
intervals.  I  usually  begin  Avith  either  hot  strong  tea,  without  milk,  or 
with  brandy-and-water  (1 :  2),  at  first  a  teaspoonful  at  a  time,  repeating 
the  quantity  every  minute,  then  giving  a  tablespoonf  ul  of  any  warm 
liquid  every  five  minutes,  carefully  testing  the  capacity  of  the  stomach 
to  dispose  of  its  contents,  withholding  everything  with  the  first  premo- 
nition of  nausea,  until  milk,  broths,  tea,  gruel,  and  the  like  are  found 
to  be  tolerated  in  ordinary  quantities.  Fluid  nourishment  should  be 
continued  hourly,  with  ice  and  water  in  the  intervals,  according  to  the 
thirst  experienced,  until  the  radial  pulse  is  restored  to  its  normal  full- 
ness. For  the  successful  management  of  these  cases  it  is  necessary  that 
the  physician  assume  the  entire  charge.  It  is  not  possible  to  give  direc- 
tions to  a  nurse  which  may  not  at  any  moment  require  modification. 

In  cases  of  excessive  loss  of  blood  a  tourniquet  to  each  femoral  ar- 
tery, a  roller  bandage,  or,  better  still,  an  Esmarch  bandage  applied  the 
length  of  the  lower  extremities,  may  be  temporarily  employed  with  a 
view  to  saving  the  limited  amount  of  blood  in  the  circulation  for  the 
important  organs  of  the  trunk  and  for  the  nerve-centers. 

Where  the  pulse  is  extremely  rapid,  the  subcutaneous  injection  of 
one  fiftieth  of  a  grain  of  digitalin  is  reported  to  act  favorably  by  caus- 
ing contractions  of  the  arterioles  and  of  the  uterus. 

O^nates  should  be  administered  from  time  to  time  during  convales- 
cence, the  frequency  and  quantity  depending  upon  the  intensity  of  the 
headache  which  acute  anaemia  induces. 

*  Otto  Leichtexsterx,  Ueher  Koohsalz  infusion  bci  Verblutungen,  Yolk- 
maun'sche,  Sammhing,  No.  25,  Xeue  Fol^c,  p.  253. 


592  THE  PATHOLOGY  OF  LABOR. 

The  Puerperal  Haemorrhages.— Ha?morrliages  occurring  after  the 
first  day  following  confinement  are  the  result  either  of  the  separation 
of  the  thrombi  from  the  placental  site  or  of  a  congested  condition  of 
the  endometrium. 

Before  the  consolidation  of  the  thrombi  is  completed,  the  mouths 
of  single  vessels  may  be  opened  by  any  sudden  increase  of  pressure  in 
the  uterine  vessels.  A  relaxed  state  of  the  uterus,  obstacles  to  retrac- 
tion, fecal  accumulations,  and  malpositions  of  the  uterus  predispose  to 
the  occurrence  of  haemorrhage.  Common  causes  of  late  haemorrhages 
are  sitting  up  or  leaving  the  bed  at  too  early  a  period,  exertions  in  car- 
ing for  the  infant,  and  straining  at  stool.  In  the  case  of  a  small,  thin 
woman  who  flowed  profusely  in  the  second  week,  I  found  the  uterus 
crowded  backward  and  downward  to  the  pelvic  floor  by  the  compress, 
which  had  been  too  tightly  bandaged  upon  tlie  abdomen  by  the  indis- 
creet zeal  of  the  nurse. 

Where  portions  of  the  ovum  have  been  allowed  to  remain  behind 
in  the  uterus,  they  may  lead  to  the  formation  of  fibrinous  polypi, 
which,  as  in  the  non-puerperal  uterus,  occasion  a  vascular  condition  of 
the  mucous  membrane,  and  become  the  cause  of  protracted  bleeding. 

The  treatment  of  late  haemorrhages  consists  in  rest  in  the  horizon- 
tal position,  in  carefully  regulated  diet,  in  emptying  both  bladder  and 
rectum,  in  the  correction  of  displacements,  and  in  the  use  of  hot  vagi- 
nal injections.  In  excessive  anteve'rsion  a  compress  above  the  pubes 
is  indicated ;  in  retro-displacements,  lifting  the  uterus  into  position, 
maintaining  it  in  place  by  a  suitable  pessary,  is  often  at  once  followed 
by  relief.  If  other  causes  can  be  excluded  the  uterine  cavity  should 
be  explored,  and  retained  bodies,  if  found  present,  should  be  removed. 
When  the  cervix  is  patulous  this  can  be  accomplished  by  the  finger ; 
if  the  cervix  is  partially  closed,  or  if  inflammation  be  present,  the  wire 
curette,  can  be  used,  as  after  abortion,  without  preliminary  dilatation. 
In  curetting  the  uterus  the  operator  should  be  mindful  of  the  delicacy 
of  the  newly  forming  mucous  membrane,  and  should  feel  carefully  for 
the  offending  bodies.  If  the  bleeding  continues  the  uterine  cavity  may 
be  tamponed  with  iodoform  gauzeN- 

Retaixed  Placenta. 

Retained  placenta  is  so  frequently  a  cause  of  hindered  uterine  re- 
traction that  a  few  words  concerning  the  etiology  and  treatment  of 
the  condition  form  an  appropriate  appendix  to  the  discussion  of  post- 
partum haemorrhage. 

Cases  of  so-called  placental  retention  are  often  simply  the  result  of 
injudicious  management.  Thus,  they  may  be  caused  by  pulling  in 
such  a  way  upon  the  cord  as  to  draw  the  center  of  the  placenta  into 
the  cervix,  so  that,  without  allowing  air  to  pass  by  the  placenta  to  the 
uterine  cavity,  extraction  is  rendered  impossible;    or,  Avhen    Crede's 


POST-PARTUM   HEMORRHAGE   AND   RETAINED   PLACENTA.     593 

method  is  practiced,  the  operator  may,  by  pressing  the  fundus  forward 
against  the  pubes  instead  of  downward  in  the  axis  of  the  pelvis,  pro- 
duce an  acute  anteflexion,  with  stenosis  of  the  lower  uterine  canal. 

True  retentian  may  be  due  to  the^  large  size  of  the  placenta  or  to 
pathological  adhesions,  either  of  the  placenta  itself  or  of  the  chorion. 

An  adherent_j)lacenta  is  of  rare  occurrence,  and  can  usually  be 
traced  to  a  bygone  endometritis.  Separation  normally  takes  place  in 
the  areolar  layer.  If  the  glandular  walls  which  constitute  the  septa 
of  the  areola  consist  of  tough  intercellular  substance  instead  of  soft 
tissue  abundantly  supplied  with  cells,  the  separation  does  not  take 
place,  and  the  placenta  remains  adherent.  The  thick  bands  which 
have  to  be  severed  in  removing  the  placenta  are  in  general  the  straight 
trunks  of  the  villi,  which  run  from  the  chorion  to  the  serotina,  the 
separation  taking  place  not  in  the  decidual  but  in  the  fetal  layer.  In 
placentitis  the  bands  consist  of  thickened  decidual  tissue  extending 
between  the  cotyledons.  In  either  case  the  serotina  is  left  nearly  or 
quite  entire;  in  some  instances,  owing  to  their  firm  attachment,  whole 
lobules  may  be  left  behind. 

Adhesions  of  the  chorion  may  be  due  to  thickening  of  the  septa 
in  the  areolar  layer ;  to  defective  involution  of  the  cell-layer  of  the 
decidua,  thickened  portions  of  which  in  consequence  remain  attached 
to  the  separated  chorion ;  to  secondary  adhesions  from  consolidated 
masses  of  fibrine,  the  remains  of  apoplectic  effusions  into  the  decidua ; 
and,  perhaps,  to  excessive  development  of  villi  upon  portions  of  the 
smooth  chorion,  from  which  proceed  thick  bands  which  are  firmly 
united  to  the  decidua  (Spiegelberg).  Adhesions  of  the  chorion  inter- 
fere with  the  separation  of  the  placenta  only  when  situated  high  up  or 
around  the  placental  border. 

The  Artificial  Separation  of  the  Placenta.— AVhenever  compression 
of  the  uterus  proves  unavailing  to  procure  the  expulsion  of  the  pla- 
centa, the  operator  should  seek  to  aid  the  delivery  by  the  resources  of 
art.  To  leave  the  placenta  within  the  uterus  not  only  exposes  the 
patient  to  the  risks  of  haemorrhage,  but  to  the  even  greater  danger  of 
decomposition  and  of  septic  poisoning.  A  digital  examination  will 
indicate  the  proper  course  to  be  pursued.  If  the  placenta  be  found 
covering  the  os,  a  finger  should  be  introduced  to  bring  down  a  placen- 
tal border.  If  no  adhesions  exist,  moderate  tractions  upon  the  cord 
will  then  suffice  to  deliver  the  placenta.  Spiegelberg  recommends 
using  the  vaginal  finger  as  a  pulley  to  cause  the  tractions  upon  the 
placenta  to  be  made  in  a  vertical  direction. 

If  tractions  upon  the  cord  are  insufficient,  or  if  the  cord  begins  to 
tear,  the  outer  hand  should  make  counter-pressure  upon  the  fundus, 
while  the  fingers  of  the  vaginal  hand  are  passed  upward  into  the  uter- 
ine cavity.  At  first  a  point  should  be  selected  where  the  placenta  is 
already  partially  detached,  and  the  fingers  should  be  employed  to  roll 
38 


594  THE  PATHOLOGY  OP  LABOR. 

the  placenta  away  from  the  uterine  wall.  If  the  attachment  of  the 
placenta  is  firm,  the  fingers  should  be  extended  with  the  back  of  the 
hand  to  the  uterus,  and  the  separation  attempted  by  a  side-to-side 
movement,  as  in  cutting  the  leaves  of  a  book.  Contractions  are  here 
of  great  service,  as  they  both  facilitate  the  separation  and  serve  to  ren- 
der distinct  the  border-line  between  the  placenta  and  the  uterus. 
Hildebrandt  advises  following  the  cord  upward  and  separating  the 
placenta  with  the  hand  covered  by  the  membranes,  as  a  means  of 
avoiding  the  dangers  of  infection  and  of  injuring  the  internal  uterine 
surface.  Spiegelberg  says  that  in  his  experience  this  method  has  suc- 
ceeded only  where  the  placental  attachment  was  loose  and  the  separa- 
tion easy. 

Bands  should  be  divided  by  pressing  them  between  the  thumb-nail 
and  the  index-finger.  When  the  placenta  is  situated  upon  the  anterior 
wall,  the  patient  should  be  placed  upon  the  side.  When  the  placenta 
is  everywhere  adherent,  a  thickened  border  should  be  chosen  as  the 
point  for  commencing  the  detachment.  In  a  very  thin,  diffused  pla- 
centa, it  has  been  proposed  by  Ilohl  to  inject  the  vessels  through  the 
umbilical  vein. 

The  operati9n  of  separating  the  placenta  should  never  be  per- 
formed hurriedly.  Every  pains  should  be  taken  to  avoid  injuring  the 
uterine  surface,  and  as  little  jjlacental  tissue  as  j)0ssible  should  be  left 
behind. 

When  the  detachment  of  the  placenta  is  completed,  it  should  be 
grasped  from  above  in  the  full  hand,  and  its  expulsion  should  be 
effected  by  external  pressure.  If  portions  of  the  membranes  are  torn 
away  during  delivery,  they  should  be  sought  for  and  carefully  re- 
moved. 

In  every  case  of  artificial  placental  delivery  the  cavity  of  the  uterus 
should  subsequently  be  thoroughly  irrigated  with  warm  carbolized 
water. 


CHAPTER   XXXII. 

PLACENTA    PREVIA.  — ACCIDENTAL    HAEMORRHAGE.  — INVER- 
SION OF  THE    UTERUS. 

Situation.— Varieties.— Frequency.— Causes  of  haemorrhage.— Clinical  features.— 
Prognosis.  —  Diagnosis.— Treatment.— Accidental  haemorrhage.- Inversion  of 
the  uterus. 

Situation.— Normally  the  placenta,  as  we  know,  is  situated  at  the 
fundus  and  upon  the  side  walls  of  the  uterus.  It  is  said  to  be  prcBvia 
when  it  occupies  that  portion  of  the  uterus  which  is  subject  to  disten- 
tion during  labor,  or,  in  other  words,  to  the  spherical  surface  of  the 


PLACENTA   PREVIA.  595 

lower  portion  of  the  uterus.  Its  clinical  importance  is  proportioned 
to  the  extent  of  the  placental  segment  which  overlaps  the  os  internum. 
Hence  it  is  customary  to  distinguish — 

Varieties. — 1.  Placenta  prcBvia  centralis,  where,  after  the  dilata- 
tion of  the  OS  internum  has  become  complete,  the  placenta  only  can  be 
felt. 

2.  Placenta  jircevia  partialis,  where,  with  dilated  os,  there  is  recog- 
nizable a  portion  of  the  membranes,  as  well  as  a  segment  of  the  pla- 
centa. 

3.  Placenta  prcBvia  lateralis,  or  marginalis,  where  the  placental 
border  stretches  down  to,  but  not  beyond,  the  margin  of  the  inner  cer- 
vical ring. 

Observations  which  tend  to  prove  the  attachment  of  the  placenta  in 
part  to  the  cervical  mucous  membrane  are  unquestionably  erroneous. 
The  fact,  first  stubbornly  insisted  upon  by  Professor  I.  E.  Taylor,  has, 
at  least  among  jDhysiologists,  passed  beyond  the  realm  of  dispute. 
Kuhn,*  who  investigated  the  subject  in  conjunction  with  Carl  Braun, 
found  that  in  no  case  was  the  placental  portion  which  occupied  the 
cervical  canal  adherent  to  the  canal-walls,  but  that  in  all  post-morteni 
examinations  the  remains  of  the  jilacenta  prgevia  materna  ended  by  a 
sharp  border-line  at  the  os  internum. 

An  exact  central  implantation  of  the  placenta  is  extremely  rare, 
though  its  occurrence  is  not  impossible.  Usually  in  the  so-called  cen- 
tral form  not  more  than  one  sixth  to  one  fourth  of  the  placental  sur- 
face overlaps  the  os  internum.  The  smaller  segment  is  oftener  found 
upon  the  left  side  (37  :56,  statistics  of  L.  Muller).f 

Owing  to  the  deficient  thickness  of  the  decidua  in  the  vicinity  of 
the  internal  os,  the  placental  villi  grow  with  less  profusion  at  that 
point,  while  by  way  of  compensation  in  more  favored  localities  they 
attain  to  an  excessive  development.  The  placenta  thus  assumes  a  char- 
acteristic uneven  appearance.  If  the  atrophic  conditions  exist  over  a 
wide  extent,  the  surface  of  the  placenta  is,  as  a  rule,  correspondingly 
increased. 

Another  peculiarity  not  devoid  of  practical  interest  is  the  frequency 
w^th  which  the  placenta  is  found  adherent  to  the  uterine  walls.  Of 
142  cases,  L.  M tiller  showed  that  in  56  adhesions  existed.  The  inser- 
tion of  the  cord  into  the  placenta  is  usually  eccentric,  often  marginal, 
and  sometimes  velamentous.  As  a  consequence,  prolapsed  funis  is  a 
common  accompaniment  of  the  anomaly. 

Fortunately,  placenta  praevia  is  of  rare  occurrence.  Miiller,  by  add- 
ing together  the  statistics  of  various  investigators,  found  reported  813 

*  Braun,  Lehrbuch  der  ges.  Gynaek.,  p.  555. 

t  LuDWiG  MuLLER,  Placenta  Praevia.  Stuttgart.  1877.  Most  of  ray  statistics  are 
taken  from  this  work.  They  include  those  of  Trask  (Am.  Jour,  of  the  Med.  Sci., 
1856,  vol.  viii)  and  of  most  of  the  later  writers,  up  to  date  of  publication. 


596 


THE  PATHOLOGY  OF  LABOR. 


instances  in  876,432  births,  or  not  quite  one  case  in  a  thousand.  Since 
the  opening  of  the  Emergency  Hospital  in  this  city  there  have  been 
between  1,500  and  1,600  women  confined  in  that  institution.  So  far 
there  has  been  no  case  of  placenta  praevia.  Lomer,*  on  the  other  hand, 
estimates  the  minimum  frequency  in  Berlin  at  one  in  723  births. 

Etiology. — The  causes  are  unknown.  The  proportion  of  multiparte 
to  primipara3  is  very  large  (6  :  l).f  Placenta  prsevia  is  most  frequent 
in  women  who  have  borne  children  with  great  rapidity,  and  in  preg- 
nancies shortly  following  abortions,  conditions  which  favor  relaxation 
of  the  uterine  walls,  dilatation  of  the  cavity,  and  defective  development 
of  the  decidua.  Miiller  advances  the  theory  that  the  descent  of  the 
ovum  is  effected  by  contractions  of  the  uterus  soon  after  conception. 
Such  expulsive  pains  naturally  lead  to  abortion.  In  certain  cases,  how- 
ever, where  the  reflexa  is  absent,  we  have  seen  that  the  ovum  may  be 
forced  downward  into  the  cervical  canal,  and  lingering  there  may  give 
rise  to  "  cervical  pregnancy."  Placenta  prajvia  Miiller  believes  to  be 
due  to  an  abortion  begun  at  an  early  period,  but  arrested  at  the  lower 
uterine  segment  to  which  the  villi  attach  themselves,  and  enable  the 
rescued  ovum  to  continue  its  development.  Ingleby  relates  two  curi- 
ous cases  where  the  orifices  of  the  Fallojjian  tubes  opened  near  the  os 
internum,  in  one  of  which  placenta  praevia  occurred  three  times,  and 
in  the  other  ten  times. 

Clinical  Features. — The  chief  clinical  importance  of  placenta  prae- 
via results  from  the  mode  of  its  detachment  during  labor.  In  normal 
positions  the  separation  of  the  placenta  is  elfected  by  virtue  of  the 
uterine  contractions  after  the  foetus  has  for  the  most  part  been  ex- 
pelled. In  placenta  praevia  the  separation  is  due  to  the  stretching  to 
which  the  lower  uterine  zone  is  subjected  in  its  conversion  from  a  half- 
sphere  to  a  cylindrical  canal,  to  permit  the  passage  of  the  child.  The 
extent  of  unavoidable  separation  in  advance  of  delivery  is  consequently 
measured  by  the  dimensions  of  the  child's  head,  the  largest  circumfer- 
ence of  which  is  estimated  as  equivalent  to  a  circle  with  a  diameter  of 
four  and  a  half  inches.  According  to  Duncan,  the  plane  at  which 
spontaneous  detachment  ceases  is  reached  at  a  distance  of  two  and  a 
half  inches  by  following  the  curve  of  the  lower  segment,  and  of  one  inch 
and  a  half  if  measured  in  the  direction  of  the  uterine  axis.  Whereas, 
in  normal  labor,  the  contractions  of  the  uterus  which  determine  pla- 
cental separation  close  at  the  same  time  the  orifices  of  the  torn  vessels, 
tlie  stretching  of  the  lower  segment  in  placenta  praevia  leaves  tlie 
mouths  of  the  sinuses  gaping,  from  which  the  blood  pours  until  the 

*  Lomer,  Combined  Turning  in  the  Treatment  of  Placenta  Praevia,  Am.  Jour,  of 
Obstet.,  December,  1884,  p.  248. 

t  Miiller  collected  from  different  reporters  1.574  cases— 227  of  primipara^  and 
1,347  of  multipara?.  Jiidell  reports  the  multipara?  at  90  per  cent.  King  (Am. 
.lour,  of  Obstet.,  October,  1880,  p.  751)  reports  183  cases  collected  in  the  State  of 
Indiana,  in  which  the  proportion  was  20  primiparae  to  103  multiparse. 


PLACENTA   PR.EVIA. 


597 


stream  is  arrested  either  by  art  or  by  the  supervention  of  syncope.  Ag 
the  haemorrhage  in  such  cases  is  the  natural  sequence  of  cervical  dila- 
tation, its  occurrence  during  labor  was  termed  by  Rigby  "  unavoida- 
ble "  in  contradistinction  to  hajmorrhages  from  detachment  of  the  pla- 
centa when  situated  near  the  fundus, 
where  the  separation  is  attributable  to 
"  accidental "  causes. 

The  hemorrhages  of  placenta  pra3- 
via  are  not,  however,  limited  to  the 
parturient  period.  Indeed,  there  is  no 
time  in  pregnancy  when  they  may  not 
occur.  When  we  consider  that  every 
jar  of  the  body  affects  the  lower  seg- 
ment with  more  force  than  the  fundus, 
and  that  the  thinned  walls  of  the  utero- 
placental vessels  are  subject  to  increased 
pressure  in  placental  presentations,  it 
becomes  evident  that  a  very  slight  occa- 
sion is  sufficient  to  produce  rupture  and 
haemorrhage.  Thus  placenta  praevia  is 
a  common  cause  of  the  pseudo-menstru- 
ation of  pregnancy;  it  creates  a  pre- 
disposition to  abortion,  and,  later  in 
gestation,  to  premature  labor,  the  haem- 
orrhages being  due  probably  in  the 
first  instance  to  accidental  causes  and 

not  to  labor-pains.  Not  every  case  of  haemorrhage  is,  however,  fol- 
lowed by  labor.  Indeed,  in  many  instances  thrombi  form  in  the  open 
vessels,  the  bleeding  becomes  arrested,  and  pregnancy  goes  on  for  a 
time  undisturbed.  The  tables  of  Miiller  show  that  in  complete  pla- 
centa previa  the  first  hsemorrhage  occurs  with  the  greatest  frequency 
between  the  twenty-eighth  and  thirty-sixth  weeks,  while  in  the  in- 
complete form  it  takes  place  most  commonly  after  the  thirty-second 
week.  In  placenta  praevia  lateralis,  haemorrhages  are  sometimes  absent 
up  to  the  time  of  labor.  Cases  of  pregnancy,  and  in  part  of  labor, 
without  hemorrhage  have  been  observed  where  the  death  of  the  foetus 
has  been  followed  by  atrophic  changes  in  the  placenta.  The  recur- 
rence of  haemorrhage  is  oftentimes  prevented  by  secondary  shrinkage 
of  the  placenta,  due  to  pressure  from  the  effused  blood  or  to  throm- 
bosis of  the  vessels  which  supply  the  implicated  cotyledons. 

The  hemorrhages  of  placenta  previa  are  usually  sudden  without 
premonitory  warnings,  without  pain,  often  without  any  apparent  occa- 
sion, sometimes  occurring  at  the  time  of  urination,  sometimes  during 
sleep.  The  quantity  of  blood  lost  in  a  single  hemorrhage  depends 
upon  the  extent  of  the  placental  separation.     The  first  outpouring  may 


Fig.  225.— Diagram  shoving  the  unavoid- 
able placental  separation  as  a  conse- 
quence of  cervical  dilatation. 


gQg  THE  PATHOLOGY  OP  LABOR. 

lead  to  intense  anemia,  and  if  repeated  at  a  short  iiiterval  may  cause 
death.  It  is  estimated  that  from  one  to  three  pounds  of  blood  may  be 
lost  in  a  single  attack,  and  from  four  to  five  pounds  in  the  course  of 
labor  (Miiller).  As  a  rule,  however,  the  haemorrhages  of  pregnancy 
are  at  first  moderate  in  character,  increasing  in  violence  with  each  rep- 
etition. A  very  formidable  variety  is  the  so-called  '^  stillicidium," 
where  the  blood  issues  drop  by  drop  for  days  and  even  weeks  in  suc- 
cession. The  most  violent  hemorrhages  occur  generally  in  the  earlier 
part  of  the  first  stage  of  labor.  As  a  rule,  the  extent  of  the  haemor- 
rhage is  proportioned  to  the  area  of  the  placental  segment  attached  to 
the  uterine  surface  subject  to  distention.  The  hemorrhage  generally 
ceases  when  the  separation  of  the  cotyledons  is  completed  and,  after 
the  rupture  of  the  membranes,  the  pressure  of  the  presenting  part  is 
brought  to  bear  upon  the  bleeding  surface.  During  the  height  of 
the  pains,  too,  the  haemorrhage  is  for  the  moment  arrested  (Spiegel- 
berg).* 

The  number  of  abnormal  presentations  in  placenta  praevia  is  very 
large.  Thus,  in  Miiller's  statistics,  in  1,148  cases  there  were  272  trans- 
verse and  107  breech  presentations.  The  frequency  of  the  anomalies 
is  partly  attributable  to  the  large  proportion  of  premature  labors,  and 
partly  to  the  width  and  lax  condition  of  tlie  lower  segment,  and  the 
consequent  want  of  stability  in  the  foetus. 

During  the  first  stage  of  labor  the  pains  are  apt  to  be  feeble  and 
the  dilatation  tardy.  The  causes  of  inertia  are  to  be  found  in  the  thin- 
ning of  the  muscular  structures  in  the  lower  segment  from  the  enor- 
mous development  of  the  utero-placental  vessels ;  in  the  attachment  of 
the  placenta  over  the  os,  which  mechjinically  hinders  dilatation ;  and 
in  the  fact  that  the  ovum  does  not  press  directly  upon  the  sensitive 
nerves  of  the  cervix.  Secondary  weakness  often  follows  the  continued 
losses  of  blood  and  the  prolongation  of  the  first  stage.  "When  the  ob- 
stacle afforded  by  the  placenta  to  dilatation  has  been  overcome,  and, 
consecutive  to  rupture  of  the  membranes,  the  uterus  retracts,  in  many 
cases  the  scene  speedily  changes,  and,  in  place  of  ineffective  contrac- 
tions, normal  and  often  powerful  pains  develop. 

As  a  rule,  quite  early  in  labor  the  cervix  is  found  soft  and  dilat- 
able ;  but  to  this  rule  there  are  numerous  exceptions.  Strictures  and 
rigidity  Miiller  computes  to  exist  in  about  twelve  per  cent  of  the  cases. 

Where  the  loss  of  blood  in  labor  is  continuous  the  woman  grows 
restless  and  complains  of  headache  and  vertigo ;  the  respirations  become 
short,  interrupted,  and  sighing,  and  the  pulse  small,  weak,  and  thready. 
Toward  the  close  unconsciousness  develops,  the  brow  is  bedewed  with 

*  This  view  was  first  advanced  by  Fountain  in  the  Am.  Jour,  of  the  Med.  Sci. 
It  has  since  been  advocated  by  Duncan,  Jiidell.  Frankel,  Spiegelberg,  and  others. 
Miiller  and  Kuhn,  however,  dispute  it,  as  justified  neither  by  theory  nor  by  ob- 
servation. 


PLACENTA   PR.EVIA.  599 

cold,  clammy  perspiration,  and  finally  convulsions  usher  in  the  fatal 
termination. 

Even  after  labor  is  over  the  danger  is  not  ended.  Post-partum  hem- 
orrhage may  result  from  atony  of  the  placental  surface  of  the  uterus, 
or,  after  good  contractions  have  been  apparently  secured,  sudden  re- 
laxation may  follow,  and  the  blood  pour  out  in  a  torrent,  so  that  the 
patient  becomes  a  corpse  before  assistance  can  be  rendered.  Again,  in 
childbed  the  imperfect  contraction  of  the  uterus  at  times  allows  the 
lochia  to  form  a  stagnant  pool  at  the  fundus,  whence  an  ichorous  dis- 
charge flows  constantly  downward  over  the  thinned  walls  and  open 
mouths  of  the  vessels  at  the  placental  wound.  The  feeble  circulation 
predisposes  to  the  formation  of  thrombi,  which,  when  poisoned  and 
disintegrated,  are  conveyed  into  the  general  circulation  and  give  rise  to 
the  dreaded  symptoms  of  pyemia.  Mtiller  found  in  two  hundred  and 
seventy-three  of  his  cases  specific  information  given  regarding  the 
puerperal  state.  "  Puerperal  fever  "  was  recorded  of  seventy-nine  pa- 
tients, with  fifty-four  deaths. 

Prognosis.— The  prognosis  of  placenta  praevia  is  necessarily  ex- 
tremely unfavorable.  As  many  as  one  mother  in  four  dies  during  or 
shortly  after  delivery.  Including  deaths  from  puerperal  jirocesses, 
Mtiller  estimates  the  total  mortality  at  not  less  than  from  thirty-six  to 
forty  per  cent.  Nearly  two  out  of  three  of  the  children  are  born  dead. 
More  than  one  half  of  those  born  living  die  within  the  first  ten  days. 
In  general  terms  it  may  be  stated  that  the  prognosis  is  the  more  seri- 
ous the  earlier  the  hemorrhages  begin  in  pregnancy,  the  more  profuse 
the  flow,  and  the  shorter  the  intervals  between  the  attacks.  During 
labor  favorable  conditions  are  a  vertex  presentation,  good  pains,  rapid 
dilatation,  and  an  unbroken  constitution.  The  maternal  mortality  is 
twice  as  great  in  placenta  previa  centralis  as  in  placenta  previa  later- 
alis. In  the  city  there  is  the  special  danger  of  infection ;  in  the  coun- 
try, of  delay  in  obtaining  medical  assistance.  Finally,  it  is  impossible 
to  analyze  the  statistics  of  j^lacenta  previa  without  coming  to  the  con- 
clusion that  the  result  depends  in  a  large  measure  upon  the  personal 
qualities  of  the  physician.  A  self-possessed  man,  cool,  resolute,  with 
clear  ideas  of  the  anatomical  conditions  to  be  dealt  with,  will,  if  sum- 
moned in  season,  apjjarently  dejjrive  even  placenta  previa  of  a  good 
share  of  its  terrors. 

Diagnosis. — There  are  no  signs  by  which  placenta  previa  can  be 
recognized  in  the  first  half  of  pregnancy.  It  may  occasion  abortion, 
which  is  then  characterized  by  the  absence  of  pain,  both  previous  to 
the  hemorrhage  and  during  the  period  of  expulsion.  As  a  rule,  the 
ovum  is  expelled  entire  without  rupture  of  the  membranes.  In  the 
second  half  of  pregnancy,  a  hemorrhage  occurring  suddenly,  without 
ostensible  cause  and  without  wariiing,  shoiild  always  be  regarded  with 
suspicion.     Upon  digital  exploration  in  placenta  previa  the  vaginal 


gQQ  THE  PATHOLOGY  OF  LABOR. 

fornix  is  found  soft  and  boggy,  and  occasionally  thicker  upon  the  one 
side  than  upon  the  other,  where  the  placental  presentation  is  incom- 
plete ;  ballottement  is  obscure ;  the  cervix  is  long,  wide,  and  soft,  and 
contains  at  times  vessels  which  pulsate  distinctly ;  the  cervical  canal 
permits  the  passage  of  the  finger  to  the  os  internum,  which  at  first 
offers  resistance,  but  yields  to  gentle  force.  The  diagnosis  is  rendered 
positive  only  in  cases  where  the  lower  surface  of  the  placenta  is  actu- 
ally felt  through  the  cervix,  its  rough,  spongy,  granular  texture  suf- 
ficiently distinguishing  it  from  clots  and  other  possible  sources  of  de- 
ception. 

Treatment. — The  history  of  placenta  praevia  brings  into  prominence 
the  central  point  to  be  kept  steadily  in  view  in  practice,  that  there  is 
no  safety  for  the  mother  so  long  as  pregnancy  continues.  In  a  very 
large  proportion  of  cases,  accidental  haemorrhage  occurring  in  the  first 
half  of  pregnancy  leads  to  abortion,  the  management  of  which  does  not 
differ  from  that  cf  abortions  which  take  place  in  normal  attachments 
of  the  placenta.  Of  the  one  hundred  and  twenty-eight  deaths  from 
placenta  praevia  collected  by  Miiller,  not  one  occurred  previous  to  the 
seventh  month.  In  the  latter  half  of  pregnancy,  hemorrhage  likewise 
leads  to  premature  expulsion  of  the  ovum  with  such  frequency  that  it 
is  reckoned  that  only  one  third  of  all  cases  reach  the  end  of  gestation. 

Most  authorities  advise,  in  the  presence  of  the  haemorrhages  of  ad- 
vanced pregnancy,  that  the  physician  maintain  an  attitude  of  expect- 
ancy, postponing  active  interference,  except  in  cases  where  the  loss  of 
blood  assumes  alarming  proportions,  until  the  spontaneous  advent  of 
labor.  This  policy  is  recommended  partly  in  the  interest  of  the  child, 
and  partly  because  of  the  tendency  in  premature  labor  to  rigidity  of 
the  cervix,  a  complication  which  always  in  placenta  praevia  enhances 
the  risks  of  delivery.  The  wisdom  of  delay  is,  however,  open  to  seri- 
ous question.  The  fatality  of  placenta  prajvia  is  due  not  so  much  to 
the  impotence  of  obstetrical  art  as  to  the  losses  of  blood  which  occur 
suddenly  in  the  absence  of  professional  assistance.  The  first  haemor- 
rhage, which  serves  as  a  warning  as  to  the  patient's  condition,  is  fortu- 
nately in  most  instances  slight.  With  each  recurrence,  however,  the 
flow  becomes  more  profuse.  If  the  haemorrhages  begin  before  the 
child  is  viable,  the  chances  of  saving  its  life  are  in  any  event  too  small 
to  offset  for  a  moment  the  welfare  of  the  mother.  Haemorrhages  occur- 
ring as  early  as  the  seventh  month  are,  as  a  rule,  the  result  of  complete 
placental  presentation.  To  trifle  witli  such  cases  is  the  best  way  to 
maintain  the  present  mournful  statistics.  After  the  thirty-second 
week  it  is  safe  to  say  that  the  child's  life  is  less  imperiled  by  the  in- 
duction of  premature  labor  than  by  exposing  it  to  the  dangers  of  con- 
tinued gestation. 

On  theoretical  grounds,  therefore,  the  induction  of  premature  labor 
is  to  be  regarded  as  obligatory  so  soon  as  the  diagnosis  of  placenta 


PLACENTA  PREVIA.  601 

jiraevia  is  established,  or  at  least  with  the  occurrence  of  the  first  haemor- 
rhage. The  practical  results  of  this  measure  in  the  hands  of  its  advo- 
cates *  plead  still  more  effectively  in  its  behalf.  Thus,  Dr.  Gaillard 
Thomas  f  reports  eleven  cases,  with  but  two  deaths,  one  resulting  from 
post-partum  hoemorrhage  coming  on  several  hours  after  delivery,  and 
one  from  puerperal  fever.  Hecker  X  lost  three  cases  in  forty,  Hoff- 
mann two  cases  in  thirty,  and  Spiegelberg  four  cases  in  seventy-four 
early  deliveries.*  More  recently  Murphy  ||  has  reported  fifteen  cases 
without  a  single  death.  In  this  connection  I  can  not  help  quoting  the 
following  impressive  remarks  of  Dr.  Barnes  :  "  If  the  pregnancy  have 
advanced  beyond  the  seventh  month  it  will,  as  a  general  rule,  I  think, 
be  wise  to  proceed  to  delivery,  for  the  next  htemorrhage  may  be  fatal ; 
we  can  not  tell  the  time  or  extent  of  its  occurrence,  and,  when  it  oc- 
curs, all,  perhaps,  that  we  shall  have  the  opportunity  of  doing  will  be 
to  regret  that  we  did  not  act  when  we  had  the  chance." 

In  the  management  of  placenta  praevia  it  is  very  desirable  that  the 
practitioner  should  have  a  perfectly  clear  idea  of  the  nature  of  the 
task  he  has  to  perform.  The  birth  of  the  child  can  not  take  place 
without  preliminary  expansion  of  the  cervix.  The  cervix  can  not  ex- 
pand without  detachment  of  the  placenta.  The  principal  objective 
point  of  treatment,  therefore,  is  the  haemorrhage  which  occurs  during 
the  stage  of  dilatation.  Plans  for  restricting  the  flow  within  narrow 
limits  have  been  proposed  without  number  by  masters  of  the  obstetric 
art.  The  best  plans  are  those  which  at  the  same  time  contribute  to 
shorten  labor.  The  choice  must  be  determined  by  conditions  which 
necessarily  vary  in  different  cases.  The  physician  has  at  the  outset  to 
particularly  inform  himself  as  to  whether  labor  has  begun  or  remains 
to  be  inaugurated,  as  to  whether  the  placenta  praevia  is  complete  or  in- 
complete, as  to  whether  the  presentation  is  normal  and  the  pains  are 
good,  as  to  whether  the  membranes  have  ruptured  or  are  intact,  and 
as  to  the  length  and  dilatability  of  the  cervix. 

If  the  cervix  is  long,  narrow,  and  rigid,  and  the  membranes  are 
entire,  the  vaginal  tampon  should  be  lesorted  to  as  a  temporary  expe- 
dient. The  tampon  strengthens  the  pains,  and,  by  the  compression 
it  exerts,  causes  coagulation  of  the  blood  which  escapes  from  the  uter- 
ine vessels.  Professor  I.  E.  Taylor  advises  packing  the  vagina  with  a 
surgical  bandage,  leaving  one  end  outside  the  vulva,  by  means  of  which 
it  can  be  withdrawn  without  difficulty.     Braun,  after  many  years'  ex- 

*  Premature  labor  in  profuse  or  continuous  haemorrhage  has  received  the  in- 
dorsement in  this  country  of  Thomas,  Taylor,  Parvin,  Pallen,  and  Taber  Johnson. 

t  Trans,  of  the  N.  Y.  "obstet.  Soc.  vol.  i,  p.  262. 
X  Statistics  taken  from  L.  Miiller's  monograph. 

*  Spiegelberg's  statistics  do  not,  however,  like  those  quoted  from  Thomas,  in- 
clude deaths  in  childbed.  Thus,  Spiegelberg's  complete  death-rate  reached  sixteen 
per  cent. 

II  Murphy,  Brit.  Med.  Jour.,  1884,  p.  215. 


602 


THE  PATHOLOGY   OF   LABOR. 


perience  at  Vienna  with  the  colpeurynter,  maintains  the  superiority  of 
hydrostatic  dilatation.  I  use  cotton,  made  into  disks,  and  dampened 
in  a  two-per-cent  sokition  of  carbolic  acid,  crowding  it  into  the  upper 
portion  of  the  vagina  with  the  aid  of  a  Sims  speculum.  The  choice 
does  not  appear  to  be  material  if  due  attention  be  jiaid  to  the  carrying 
out  of  aseptic  details.  Having  once  introduced  the  tampon,  the  physi- 
cian should  not  leave  his  patient  until  the  labor  is  ended.  After  at 
most  four  hours  the  tamjjon  should  be  removed,  and,  after  rendering 
the  vagina  thoroughly  aseptic,  the  cervix  should  be  examined.  A 
second  introduction  of  the  tampon  is  rarely  necessary,  or,  owing  to  the 
dangers  of  septic  infection,  expedient. 

So  soon  as  the  os  will  permit  the  passage  of  the  finger,  the  vaginal 
plug  should  be  discarded.  The  operator  will  then  have  to  choose 
between  one  of  two  jjlans  of  action,  viz.,  dilatation  of  the  cervix  by 
means  of  water-bags,  or  version  by  Braxton  Hicks's  method.  If  dilata- 
tion is  decided  upon,  a  Barnes  rul^ber-bag,  expanded  sufficiently  to 
render  the  border  of  the  os  externum  tense,  fulfills  admirably  the  prin- 
cipal indications.  It  acts  as  an  efficient  tampon,  it  strengthens  the 
pains,  and  it  dilates  the  cervical  canal.  As  the  latter  expands,  a 
larger-sized  dilator  should  be  introduced.  It  is  important,  in  order 
to  prevent  hemorrhage,  to  maintain  the  tension  of  the  external  orifice. 
On  account  of  the  softening  which  exists  in  the  lower  uterine  segment 
as  a  result  of  placenta  previa,  in  a  large  proportion  of  cases  the  cervix 
can  be  stretched  with  the  utmost  facility.  If  no  ui'gent  symptoms 
call  for  immediate  interference,  it  is  desirable  to  render  the  dilatation 
complete.  It  is  not,  however,  always  necessary.  Indeed,  Barnes, 
Taylor,  Spiegelberg,  and  Braun  advise  to  proceed  boldly  with  the  de- 
livery so  soon  as  the  os  externum  has  expanded  to  the  size  of  a  half- 
dollar,  as  by  that  time  the  expansion  of  the  os  internum  is  very  nearly 
completed,  and  as  the  soft  cervical  canal  does  not  offer  sufficient  re- 
sistance to  materially  interfere  with  the  extraction  of  the  child.  The 
distinguished  success  of  the  authorities  mentioned  in  the  field  of  prac- 
tice under  consideration  lends  great  weight  to  their  recommendations. 
It  is,  however,  more  than  probable  that  exceptional  training  and  ex- 
perience count  in  their  case  for  quite  as  much  as  the  plans  of  proced- 
ure they  individually  favor.  At  any  rate,  in  reviewing  the  statistics 
of  Trask  and  Miiller  it  becomes  evident  that  rigidity  of  the  cervix  is 
not  a  rare  event  in  placenta  praevia,  and  that  the  acconchemcnf  force, 
performed  with  a  rigid  cervical  canal,  is  perhaps,  next  to  doing  nothing, 
the  most  responsible  cause  of  the  mournful  results  they  have  placed  on 
record. 

Jungbluth  (Die  Behandlung  der  placenta  praevia,  Volkmannsche  Samm- 
lung,  No.  3,35),  advocates  the  use  of  large  sponge  tents,  rendered  aseptic  by 
careful  preparation,  {inde  p.  360),  in  placenta  praevia.  He  claims  in  their  favor 
that  they  cause  active  uterine  contractions,  and  act  as  an  efficient  tampon,  so 


PLACENTA   PREVIA.  603 

that  complete  dilatation  of  the  cervix  can  be  secured  without  loss  of  blood. 
He  directs  that  the  attendant  shall  first  ascertain  the  direction  and  width  of  the 
cervix  and  the  distance  of  the  os  externum  from  the  placenta.  He  then  selects 
a  tent  to  correspond.  With  a  sharp  knife  the  tent  should  be  cut  across  so  that 
when  introduced  its  length  shall  not  exceed  that  of  the  canal  by  more  than  an 
inch.  The  abtruncated  tent  is  to  be  seized  in  ovum  forceps,  the  cut  end  is  to  be 
dipped  for  a  moment  in  hot  water,  and  then,  under  the  guidance  of  two  fingers 
in  the  vagina  and  with  counterpressure  from  above,  the  tent  is  to  be  pushed  up 
the  canal  to  the  placenta,  and  held  in  place  for  ten  to  fifteen  minutes,  by  which 
time  the  expansion  is  sufficient  to  tampon  the  lower  uterine  segment.  Jung- 
bluth  claims  that  if  at  the  outset  the  external  parts,  the  vagina,  the  instru- 
ments, and  the  hands  of  the  operator  are  surgically  clean,  the  tent  after  its  in- 
troduction may  be  left  eight  or  ten  hours  in  situ  without  the  slightest  risk  of 
sepsis. 

Sometimes  one,  sometimes  as  many  as  three  or  four,  sponge  cylinders  are 
requisite.  If  unfilled  spaces  are  left,  small  tents  should  be  inserted  to  secure 
a  complete  tamponing  effect.  In  no  case  should  a  vaginal  tampon  be  used.  A 
comj^ress  to  the  vulva  will  show  if  any  leakage  occurs.  In  that  case  it  is  an  in- 
dication that  the  tents  have  been  faultily  placed.  They  should  then  be  removed, 
and  new  ones  should  be  introduced.  A  renewal  of  the  tents  is  likewise  re- 
quired when,  as  the  cervix  softens  and  dilates,  the  finger  can  be  pushed  at  the 
border  u])ward  to  the  placenta.  The  vagina  should  be  then  washed  with 
carbolic-acid  solution  (two  per  cent),  the  hands  disinfected,  and  the  sponges 
withdrawn  by  a  leverage  movement.  In  the  partially  expanded  cervix  three  or 
four  cylinders  tied  together  should  be  introduced  and  held  in  place  in  the 
manner  already  described.  A  third  renewal  is  rarely  necessary.  In  answer  to 
the  objection  that  the  method  is  troublesome,  Jungbluth  argues  that  trouble 
is  of  small  consideration  when  life  is  at  stake. 

After  the  cervix  has  been  duly  prepared  the  membranes  should  be 
ruptured,  and  a  part  of  the  amniotic  fluid  should  be  permitted  to 
escape.  Then,  if  the  j^lacenta  possesses  a  lateral  or  a  marginal  attach- 
ment, if  the  pelvis  is  of  normal  size  and  the  pains  strong  and  regular, 
and  if  the  head  present,  or  at  least  can  be  brought  down  and  fixed  at 
the  pelvic  brim- by  external  manipulations,  the  further  progress  of  the 
case  may  be  left  to  Nature.  Haemorrhage  will  then  be  prevented  by 
the  pressure  of  the  foetus  in  its  descent  through  the  utero-vaginal 
canal.  At  first  the  method  of  expression  advocated  by  Kristeller  is 
capable  of  rendering  important  service  by  promoting  the  speedy  en- 
gagement of  the  child's  head.  Ergot,  too,  cautiously  administered,  is 
useful  in  strengthening  the  uterine  contractions.  Even  if  tonic  con- 
traction follow  from  its  employment — an  unlikely  event  in  placenta 
prtevia — the  effect  would  be  to  close  the  sinuses  and  to  furnish  a  fresh 
barrier  against  haemorrhage.  The  forceps  may  be  applied  under  the 
same  circumstances,  and  with  the  same  restrictions,  as  in  other  con- 
ditions. Where,  however,  the  head  is  movable,  the  patient  ansemic, 
and  hfemorrhage  persistent,  version,  as  furnishing  the  more  rapid 
mode  of  delivery,  would  receive  the  preference. 


QQ^  THE   PATHOLOGY  OF  LABOR. 

In  cases  of  complete  attachment  of  the  placenta  there  should  be 
no  trifling  with  half-way  measures.  If  the  cervix  is  long  and  rigid, 
the  vaginal  tampon  should  be  employed  as  a  preliminary  measure. 
When  the  cervical  tissues  have  become  softened,  and  dilatation  has 
beo-un,  the  tampon  should  be  removed.  At  this  stage  Barnes  recom- 
mends separating  at  once  that  portion  of  the  placenta  which  is  attached 
above  the  inner  orifice  of  the  cervix.  By  so  doing,  "  we  remove  an 
obstacle  to  the  dilatation  of  the  cervix,  for  the  adherent  placenta  acts 
as  an  impediment."  The  operation  is  performed  as  follows:  "Pass 
one  or  two  fingers,  as  far  as  they  will  go,  through  the  os  uteri,  the 
hand  being  passe"  into  the  vagina  if  necessary;  feeling  the  placenta, 
insinuate  the  finger  between  it  and  the  uterine  wall ;  sweep  the  finger 
around  in  a  circle,  so  as  to  separate  the  placenta  as  far  as  the  finger 
can  reach.  .  .  .  Commoi\ly  some  amount  of  retraction  of  the  cervix 
takes  place  after  this  operation,  and  often  the  haemorrhage  ceases."  * 
Next  put  in  a  Barnes  dilator  and  rapidly  expand  the  cervix.  Mean- 
time try  and  bring  the  breech  down  into  the  lower  uterine  segment  by 
external  palpation.  Both  Taylor  and  Braun  have  found  external  ver- 
sion easy,  on  account  of  the  inert  conditions  of  the  uterine  walls.  When 
the  cervix  has  been  sufficiently  stretched  to  admit  of  delivery,  two  fingers 
should  be  introduced,  the  placenta  should  be  separated,  the  memlu'anes 
ruptured,  and  an  extremity  should  be  seized  without  passing  the  entire 
hand  into  the  uterus.  Extraction  should  then  follow,  the  pressure  of 
the  foetus  preventing  any  considerable  amount  of  haemorrhage. 

Usually  the  right  hand  is  chosen  to  seek  the  feet,  as  the  placenta 
more  frequently  overlaps  the  left  side.  Often  a  hint  is  furnished  by 
the  fact  that  the  overlapping  portion  of  the  placenta  is  separated  to  a 
greater  extent  than  the  main  body.  Many  times,  however,  it  will  be 
necessary  to  change  the  direction  of  the  fingers  before  the  edge  of  the 
placenta  is  reached.  If  external  version  can  not  be  effected,  the  opera- 
tor should  push  the  hand  forward  into  the  uterus  to  find  an  extremity. 
The  arm  acts  during  the  search  as  a  temporary  tampon.  Ha?morrhage, 
which  follows  the  withdrawal  of  the  arm,  will  be  arrested  by  the  de- 
scent of  the  breech. 

The  accidental  rupture  of  the  membranes  before  the  cervix  is  pre- 
pared for  artificial  delivery  is  hardly  likely  to  occur  in  cases  of  placenta 
praevia  comi)leta.  In  cases  of  marginal  implantation,  dilatation  with 
water-bags  should  be  employed  in  such  a  way  as  to  compress  the  open 
sinuses  from  which  bleeding  takes  place. 

*  Barnes,  Obstetrical  Operations,  p.  503.  The  artificial  separation  of  the 
placenta  is  unquestionably  of  service  where  it  can  be  accomplished  without  dif- 
ficulty. Much  time  should  not,  however,  be  lost  in  fruitless  efforts,  nor  is  it  de- 
sirable to  persist  if  the  separation  can  not  be  accomplished  smoothly.  Behm, 
Hofmeier,  and  Lomer  all  urge  in  such  cases  passing  the  fin<;ers  directly  through 
the  placental  tissue.  The  most  alarming  hsemorr"haf5~Teases  when  the  leg  is 
brought  down. 


PLACENTA   PREVIA.  6O5 

In  1861  Braxton  Hicks  recommended  for  the  treatment  of  placenta 
praevia  turning  the  child  by  the  two-finger  method  in  an  early  stage  of 
labor,  and,  after  rupture  of  the  membranes,  bringing  down  the  breech 
to  tampon  the  bleeding  vessels.  This  practice  has  been  followed  with 
distinguished  success  by  Hof meier  *  and  Behm  f  and  in  the  University 
Hospital  for  AVomen,  in  Berlin.  The  cases  reported  from  the  latter 
institution  by  Lomer|  were  101,  operated  upon  by  nine  different  assist- 
ants, with  a  total  of  7  deaths.  Hofmeier  reported  37  cases  with  1 
death,  and  Behm  35  cases  with  no  maternal  death.  Thus,  in  178  cases 
occurring  in  the  practice  of  11  individuals,  there  were  8  deaths,  a  mor- 
tality of  but  4-5  per  cent.  But  Lomer  had  no  death  in  16  cases.  The 
addition  of  these  latter  to  those  of  Hofmeier  and  Behm  gives  in  the 
practice  of  three  individuals  only  1  death  in  93.  To  be  sure,  the  life 
of  the  child  is  made,  by  this  premature  version,  a  secondary  considera- 
tion. Hofmeier  reports  an  infantile  mortality  of  67  per  cent,  that  of 
Behm  was  80  per  cent,  while  in  Lomer's  report  the  fetal  death-rate 
was  only  50  per  cent.  However,  many  of  the  reported  deaths  were  in 
non-viable  children,  or  were  cases  where  the  death  of  the  child  occurred 
long  prior  to  birth,  Hofmeier  advocates  following  up  version  by  the 
slow  extraction  of  the  child.  By  this  means  he  has  succeeded  in 
ending  labor  in  the  course  of  from  half  an  hour  to  one  hour  and  three 
quarters.  Behm  counsels  awaiting  the  spontaneous  expulsion  of  the 
child,  or  at  least  the  complete  dilatation  of  the  cervix.  Lomer  says : 
"  In  our  cases  we  exert  gentle  tractions  now  and  then,  until  the  cervix 
is  completely  dilated,  and  we  then  slowly  increase  the  number  and 
strength  of  the  tractions."  Lomer  sums  up  the  advantage  of  the 
method  as  follows :  1.  It  does  away  with  the  tampon,  and  the  conse- 
quent dangers  of  infection.  2.  It  allows  us  to  operate  early.  3.  It 
arrests  haemorrhage  with  great  certainty.  4.  It  gives  time  for  the 
patient  to  rally,  for  the  cervix  to  dilate,  and  for  pains  to  set  in.  It 
therefore  prevents  post-partum  hemorrhage.  I  have  recently  had 
occasion  to  test  this  plan  in  a  case  of  placenta  previa  completa,  and  am 
prepared  to  speak  most  strongly  in  its  favor,  as  both  mother  and  child 
were  saved,  though  I  still  believe  that  a  certain  amount  of  preliminary 
dilatation  with  Barnes's  bags  tends  to  enhance  the  chances  of  the  child 
without  endangering  the  life  of  the  mother. 

After  the  birth  of  the  child,  the  danger  of  post-j^artum  hemorrhage 
must  be  kept  in  mind.  Every  preparation  should  be  made  in  anticipa- 
tion of  its  occurrence.     If  bleeding  persists  after  the  fundus  is  felt  to 

*  Hofmeier.  Zur  Behandlung  der  Placenta  Pnevia,  Ztschr.  f.  Geburtsh.  und 
Gynaek.,  vol.  vii,  p.  89. 

f  Behm,  Die  combinirte  Wendung  bei  Placenta  Pra?via,  Ztschr.  f.  Geburtsh.  und 
Gynaek.,  vol.  ix,  p.  373. 

X  Lomer.  Combined  Turning  in  the  Treatment  of  Placenta  Praevia,  Am.  Jour, 
of  Obstet.,  December,  1884,  p.  1233. 


II 


Q^Q  THE  PATHOLOGY   OP  LABOR. 

be  firmly  contracted,  a  speculum  should  be  introduced,  and  the  open 
sinuses  of  the  lower  segment  should  be  swabbed  with  cotton  soaked  in 
some  styptic  form  of  iron,  as  recommended  by  Engelmann  (vide  Post- 
partum Hemorrhage).  Ergot  should  be  given  for  several  days,  as 
the  danger  of  late  hemorrhages  is  specially  great  following  placenta 

previa. 

The  utmost  cleanliness  and  the  use  of  disinfectant  vaginal  douches 
must  be  insisted  on  during  the  childbed  period,  as  the  exposure  of  the 
placental  wound  to  the  lochia,  which  constantly  flow  over  it,  renders 
the  patient  especially  liable  to  septic  infection. 

HEemorrhage  from  Normally  Implanted  Placenta.— The  placenta, 
even  when  implanted  over  the  upper  polar  circle,  the  safe  placental 
seat  of  Dr.  Barnes,  may  become  detached  to  a  greater  or  less  extent 
during  pregnancy  or  labor,  and  may  then  furnish  a  flow  of  blood  that 
either  remains  internal  and  concealed  or  may  find  its  way  between  the 
decidua  vera  and  reflexa,  and  thus  escape  into  the  vagina. 

The  hemorrhages  from  this  variety  of  placental  separation  are 
termed  "  accidental,"  in  contradistinction  to  the  "  unavoidable  "  form, 
which  is  the  accompaniment  of  placenta  previa. 

The  circumstances  under  which  concealed  hemorrhage  takes  place 
are  given  by  Goodell  *  as  follows :  (a)  When  the  placenta  is  centrally 
detached,  and  the  blood  accumulates  in  the  cul-de-sac  formed  by  the 
firm  adhesion  of  its  margins  to  the  uterine  wall,  (b)  When  the  pla- 
centa is  so  detached  that  the  blood  escapes  into  the  uterine  cavity 
behind  the  membranes  near  the  fundus,  {c)  When  membranes  are 
ruptured  near  the  detached  placenta  and  the  effused  blood  mingles 
with  the  liquor  amnii.  {d)  When  the  presenting  part  of  the  foetus  so 
accurately  plugs  up  the  maternal  outlet  that  no  existing  hemorrhage 
can  escape  externally. 

'  The  causes  of  internal  hemorrhage,  when  such  can  be  determined, 
are  for  the  most  part  similar  to  those  considered  in  connection  with 
abortion.  Thus,  the  circumstances  leading  to  placental  detachment 
Goodell  found  to  be  irregular  uterine  contractions,  external  violence, 
and  undue  exertion ;  in  seven  the  causes  were  purely  emotional,  and 
ten  took  place  during  sleep.  It  occurs  more  frequently  in  multipara 
and  in  the  latter  months  of  pregnancy. 

The  symptoms  are  an  alarming  state  of  collapse,  pain  often  excess- 
ive, absence  or  extreme  feebleness  of  the  pains  of  labor,  marked  dis- 
tention of  the  uterus,  sometimes  a  lateral  bulging  of  the  uterine  walls, 
a  show  of  blood,  a  serous  discharge,  and  blood  in  the  liquor  amnii. 

The  diagnosis  in  the  concealed  form  may  be  extremely  embarrass- 
ing.    The  pain  is  often  that  of  flatulent  colic.     The  accident  likewise 

*  Goodell.  On  Concealed  Accidental  Hapmorrhage  of  the  Gravid  Uterus  (Am. 
Jour,  of  Obstet.,  August,  1869,  p.  281).  This  paper  serves  as  a  mine  from  which 
most  subsequent  writers  have  drawn  their  data. 


PLACENTA   PRiEVIA.  G07 

presents  many  features  which  resemble  those  of  ruptured  uterus  ;  but 
rupture,  by  contrast,  rarely  occurs  until  after  the  escape  of  the  waters, 
the  presenting  part  then  receding  from  the  os,  and  the  uterus  dimin- 
ishing in  size. 

The  prognosis  is  very  unfavorable.  Goodell  reports  :  "  Out  of  one 
hundred  and  six  tabulated  cases,  fifty-four  mothers  perished ;  and  out 
of  one  hundred  and  seven  children,  six  alone  are  known  to  have  been 
saved."  I  have  had  a  case  since  his  paper,  where,  after  labor,  I  re- 
moved at  least  a  basinful  of  firm  clots  from  the  uterine  cavity,  and  yet 
both  mother  and  child  survived. 

In  cases  of  external  ha3morrhage  the  diagnosis  is  easy  and  the 
prognosis  more  favorable,  the  latter  probably  because  the  walls  are  less 
flaccid  than  in  the  concealed  form. 

The  treatment  consists  in  the  subcutaneous  injections  of  ergot,  in 
dilatation  of  the  os  with  Barnes  dilators,  in  rupture  of  the  membranes, 
and  in  version. 

In  my  own  case,  to  which  I  have  referred,  the  Barnes  dilator  acted 
capitally,  not  only  enabling  me  to  expand  the  cervix,  but  exciting  the 
uterus  to  contract  vigorously.  The  serious  symptoms  set  in  after  the 
membranes  were  ruptured,  and  compelled  me  to  deliver  with  forceps. 
In  another  case  I  should  certainly  first  dilate,  and,  after  ruptiire  of  the 
membranes,  should  choose  version  and  speedy  extraction,  and  should 
avail  myself  of  a  skilled  assistant,  whose  duty  it  should  be  to  compress 
the  uterine  walls  externally  during  the  act  of  delivery. 

Inversio  Uteri. — Inversion  of  the  uterus  is  a  rare  occurrence. 
Braun  states  that,  of  two  hundred  and  fifty  thousand  births  in  the 
clinics  respectively  under  the  charge  of  8paetli  and  himself,  not  a  sin- 
gle complete  inversion  has  come  to  their  notice.  There  was  one  case 
in  one  hundred  and  ninety  thousand  confinements  at  the  Eotunda 
Hospital  in  Dublin. 

The  production  of  inversion  is  favored  by  a  large,  relaxed  uterus, 
the  result  of  overdistention,  of  rapid  delivery,  or  of  haemorrhage. 
The  immediate  cause  may  be  either  pressure  exerted  from  above  or 
traction  Irom  below.  The  first  may^jproceed  from  straining  efforts, 
especially  in  a  sitting  or  kneeling  position,  or  from  attempts  at  pla- 
cental expulsion  before  u^erme  contractions  have  been  secured  ;  the 
second  may  proceed  from 'a_short  or  coiled  cord  during  expulsion, 
from  tractions  upon  the  cord  after  the  child  is  born,  or  simply  from 
the  weight  of  the  placenta.  HennTg^*^  concludes  that  the  attachment 
of  the  placenta  to  the  fundus,  instead  of  a  more  lateral  implantation,  is 
an  active  cause  of  the  accident. 

Inversion  may  be  partial  or  complete.  In  the  former  the  fundus 
})resents  a  saucer-   or  cup-like  depression ;    in  the   latter   the   entire 

*  Hennig.  Ueber  die  Ursachen  der  spontanen  Inversio  Uteri,  Arch.  f.  Gynaek., 
Bd.  vii,  p.  491. 


608 


THE  PATHOLOGY  OF  LABOR. 


fundus  descends  into  the  vagina  ;  in  extreme  instances  the  cervix  may 
be  inverted  to  tlie  vaginal  attachment.  Dr.  I.  E.  Taylor  maintains  a 
mechanism  for  a  certain  number  of  cases,  which  consists  in  a  rolling 
out  of  the  cervix,  with  gradual  implication  of  the  body  and  fundus. 

The  symptoms  of  inversion  are  shock  and  haemorrhage.  The  shock 
is  evidenced  by  the  small  pulse,  coldextremities,  vomiting,  and  sunken 
features,  and  is  due,  in  part  at  least,  to  the  sudden  diminution  of  the 
intra-abdominal  pressure  and  consequent  plethora  of  the  abdominal 
veins;  the  haemorrhage  results  from  imperfect  contraction,  and  is 
therefore  proportioned  to  the  extent  of  the  uterine  paresis. 

Spontaneous  reduction  of  incomplete  inversion  is  not  uncommon. 
Cases  of  spontaneous  reduction  of  the  complete  form  have  likewise 

been  observed,  referable,  accord- 
ing to  Spiegelberg,*  to  retrac- 
tion of  the  ligaments  acting 
upon  the  uterus  while  in  a  re- 
laxed condition. 

The  diagnosis  is  not  diffi- 
cult. The  inverted  uterus  can 
only  be  mistaken  for  a  fibrous 
polypus,  but  liy  careful  external 
and  bimanual  palpation  the  de- 
monstration of  the  absence  of 
the  uterine  tumor  above  the 
symphysis  would  guard  against 
this  error. 

Tlie  prognosis  depends  u})on 
the  promptitude  of  the  operator 
in  restoring  the  fundus  to  its 
normal  position.  Still,  accord- 
ing to  Crosse's  f  statistics,  one 
third  of  the  patients  died  either  at  once  or  within  a  month  of  the 
occurrence  of  the  accident. 

Treatment  consists  in  pressing  the  fundus  upward  with  the  fingers 
or  with  the  closed  fist.  To  avoid  tearing  the  uterus  from  its  vaginal 
attachments,  care  should  be  taken  to  employ  counter-pressure  with  the 
disengaged  hand  upon  the  upper  border  of  the  funnel-shaped  depres- 
sion. If  the  placenta  is  detached  to  any  great  extent,  its  separation 
should  be  completed  before  replacement ;  if  adherent,  no  time  should 
be  lost,  but  placenta  and  fundus  should  be  pushed  back  together.  If 
the  cervix  is  contracted  about  the  inverted  portion,  an  anaesthetic 
should  be  given,  and  taxis  should  be  employed.     I  can  speak  from  ex- 

*  Spiegelberg.  Lehrbuch,  etc.,  p.  597. 

t  Crosse,  An  Essay,  Literary  and  Practical,  on  Inversio  Uteri,  Trans,  of  the 
Provincial  Med.  and  Surg.  Assoc,  1847,  p.  344. 


Fig.  2'.i6. — Inversion  of  uterus. 


PLACENTA   PREVIA. 


609 


perience  in  favor  of  Noeggerath's  metliod,  which  consists  in  indenting 
the  uterus  in  the  neighborhood  of  a  Fallopian  tube,  in  place  of  acting 
directly  upon  the  fundus. 

In  a  case  seen  by  me  in  conjunction  with  Dr.  Henry  E.  Crarapton, 
of  New  York  city,  thirty-six  hours  after  delivery,  I  succeeded,  afttr 
several  fruitless  efforts,  in  restoring  the  uterus  by  the  following  method  : 
First,  the  fundus  was  pressed  upward  through  the  cervical  ring  by  the 
thumb  and  fingers.  The  partially  reinverted  uterus  was  clearly  felt 
through  the  thin  abdominal  parietes,  but  it  was  found  impossible  to 


Fig.  227. — First  stage  of  replacement.  Fig.  227a.— Second  stage  of  replacement. 


advance  the  hand  through  the  ring  beyond  the  knuckles.  The  hand 
was  therefore  held  steadily  in  place,  with  no  attempt  at  a  forward 
movement,  for  about  ten  minutes.  This  was  done  with  the  intent  to 
procure  a  relaxation  of  tho  constriction  by  means  of  continuous  press- 
ure. Then  the  thumb  was  withdrawn,  and  the  circular  uterine  fold, 
which  still  hung  deep  into  the  vagina,  was  pressed  up  on  one  side  by 
the  fork  formed  by  the  thumb  and  index-finger.  Finally,  by  indent- 
ing the  raised  fold  by  the  thumb,  and  at  the  same  time  making  counter- 
pressure  upon  the  uterine  ring  through  the  abdominal  walls,  I  was  en- 
abled to  push  the  entire  mass  by  the  ring,  and  had  the  pleasure  of  feel- 
ing the  remainder  of  the  inverted  organ  roll  spontaneously  into  posi- 
39 


g-j^Q  THE   PATHOLOGY  OF  LABOR. 

tion.     Tlie   diagrams  drawn  for  me  by  my  friend,  Dr.  L.  M.  Yale, 
will  help  to  make  intelligible  the  mechanism  of  the  manoeuvre. 

If  the  reinversion  proves  successful,  the  hand  should  be  allowed  to 
remain  within  the  uterus,  and  external  pressure  should  be  employed 
until  contraction  is  secured.  The  subsequent  treatment  does  not  differ 
from  that  for  uterine  atony,  already  considered  in  connection  with 
post-particm  hemorrhage. 


CHAPTER  XXXIII. 

RUPTURES  OF  THE  GENITAL  CANAL. 

Rupture  of  the  uterus. — Etiology. — Patliological  anatomy.— Symptoms  and  diag- 
nosis.— Treatment. — Prophylaxis. — Treatment  after  rupture. — Rupture  limited 
to  the  peritoneal  covering  of  the  uterus. — Perforation  from  pressure. — Lacera- 
tions of  the  vaginal  portion. — Laceration  of  the  vagina. — Laceration  of  the 
vulva. — Thrombus  of  the  vulva  and  vagina. — Rupture  of  the  pelvic  articula- 
tions. 

The  genital  canal  may  be  ruptured  in  any  portion  of  its  course. 
Thus,  lacerations  may  take  place  through  the  perina?um  and  posterior 
vaginal  wall,  in  the  vestibulum,  in  the  fornix  of  the  vagina,  in  the 
cervix,  in  the  uterus,  and  in  the  pelvic  articulations. 

Rupture  of  the  Uterus. — Ruptures  of  the  uterus,  for  the  most  part 
at  least,  start  from  the  lower  segment,  and  thence  extend  upward  to- 
ward the  body  and  fundus,  or  downward  toward  the  vagina.  They  are 
termed  complete  when  the  rent  extends  through  to  tlie  abdominal 
cavity,  and  incomplete  when  confined  to  either  the  muscular  layers  or 
to  the  peritonaeum. 

Bandl  reported  19  cases  in  40,614  labors  (1 : 2,137),  occurring  in 
nine  years  in  the  Lying-in  Hospital  at  Vienna.  Jolly,  in  Paris,  found 
230  cases  in  782,741  labors  (1:3,403),  but  he  excluded  from  his  list 
lacerations  of  the  cervix.  Harris,  whose  authority  as  a  statistician  is  of 
the  highest,  estimates  in  the  United  States  one  case  of  ruptured  uterus 
to  four  thousand  births.  I  found  47  deaths  from  this  cause  recorded 
in  New  York  between  1867  and  1875  inclusive,  or  about  one  death  in 
six  thousand  labors.  But  it  is  hardly  probable  that  these  figures  rep- 
resent anything  like'  the  actual  mortality ;  for,  whereas  in  1875  eleven 
deaths  were  returned,  there  were  but  four  recorded  in  1867,  and  none 
in  the  years  1871  and  1872.  It  is  not  likely,  moreover,  that  the  47 
cases  include  any  other  than  spontaneous  ruptures,  as  naturally  very 
few  physicians  are  brave  enough  to  record  as  such  ruptures  due  to 
violent  obstetric  manoeuvres. 

Hugenberger  estimated  the  mortality  from  ruptured  uterus  at  95 


RUPTURES  OF  THE  GENITAL  CANAL. 


611 


per  cent,  C.  Brann  *  at  89  per  cent.  Their  statistics  were  made  up 
from  hospital  records.  Jolly  reported  in  civil  practice  100  saved  in  580 
cases ;  but  this  Harris  f  believes  to  be  too  favorable  a  showing,  as  the 
proportionate  loss  is  much  less  in  published  than  in  unpublished  cases. 
Of  late  years  the  treatment  of  this  condition  has,  however,  furnished 
somewhat  better  results,  and  a  careful  study  of  the  circumstances 
which  favor  its  production  is  capable  of  at  least  furnishing  the  ground- 
work of  a  rational  prophylaxis. 

Etiology. — Rupture  of  the  uterus  may  take  place  spontaneously  as 
the  result  of  defective  resistance  offered  by  the  uterine  walls  to  the 
pressure  of  the  ovum,  or  it  may 
owe  its  origin  to  some  external 
mechanical  force. 

Kupture  of  the  fundus  is  a 
very  rare  exception.  It  may  take 
place  under  special  abnormal 
conditions,  as  in  the  one-horned 
uterus,  in  imbedded  myomata, 
when  cicatrices  exist  as  the  re- 
sult of  previous  Ca^sarean  sec- 
tion, and  in  retrograde  changes 
of  the  uterine  walls. 

It  is  the  great  merit  of  Bandl  J 
to  have  shown  that  nearly  all 
ruptures  begin  in  the  lower  seg- 
ment, and  are  preceded  by  an  ab- 
normal thinning  and  distention 
of  that  portion  of  the  uterus  situ- 
ated between  the  ring  which 
bears  his  name  and  the  os  ex- 
ternum. In  normal  labor  it  will 
be  remembered  that  during  a 
pain  the  fundus  and  body  thick- 
en, while  the  lower  segment  is 

stretched  by  the  ovum.  So  long  as  no  obstacle  exists  which  hinders 
the  progression  of  the  ovum  or  the  fcetus,  this  process  ends  in  the 
conversion  of  the  uterus  and  vagina  into  one  continuous  canal.  In 
such  cases  the  contraction  ring  is  often  but  slightly  indicated,  and  is 
found  in  the  neighborhood  of  the  pelvic  brim. 

If,  however,  the  descent  of  the  foetus  is  prevented  by  any  cause,  the 
resistance  of  the  ligaments  which  hold  the  uterus  in  position  is  over- 

*  Braun,  Lehrbuch  der  gesammt.  Gynaek.,  p.  699. 

f  Harris,  If  a  Woman  has  ruptured  her  Uterus,  what  shall  be  done  in  order  to 
save  her  Life?  Am.  Jour,  of  Obst.,  October,  1880. 

J  Bandl,  Ueber  Ruptur  der  Gebarmutter,  Wien,  1875. 


Fig.  228. — Diagram  showing  dangerous  thinning 
of  the  lower  segment,  owing  to  the  non- 
descent  of  the  head  in  contracted  pelvis. 
(Bandl.) 


gj^2  THE   PATHOLOGY   OF   LABOR. 

come  by  the  retraction  of  tlie  fundus  and  body,  and  as  a  consequence 
the  contraction  ring  is  withdrawn  upward,  the  lower  segment  is 
thinned,  and  in  extreme  cases  nearly  the  entire  uterine  contents  may 
occupy  the  distended  passive  inferior  segment.  Under  these  circum- 
stances it  is  possible  at  times  to  detect  by  palpation  the  contraction 
ring  a  hand's-breadth  above  the  pubes,  or  even  in  the  neighborhood  of 
the  umbilicus.  The  stretching  of  the  tissues  is  most  pronounced  in  the 
upper  portion  of  the  lower  segment,  diminishing  below  until  the  vagi- 
nal portion  is  reached,  which,  of  course,  is  not  subjected  to  tension. 

Now,  when,  as  the  result  of  the  birth  of  any  considerable  portion 
of  the  child  into  the  obstetrical  cervix — as  the  stretched  lower  uterine 
segment  has  been  termed  by  Spiegelberg — the  tissues  of  the  latter 
are  distended  so  as  to  form  little  more  than  a  membranous  covering, 
the  conditions  which  threaten  rupture  are  established.  Thus,  contrac- 
tility is  impaired;  with  each  recurring  pain,  the  child,  driven  still 
farther  from  the  uterine  cavity,  increases  the  pressure  upon  the  already 
enormously  distended  lower  segment ;  gradually  the  thinned  tissues 
separate ;  the  presenting  part  of  the  child  is  forced  into  the  opening ; 
at  the  height  of  a  pain  complete  separation  of  the  muscular  tissues 
takes  place  ;  the  peritoneum  is  lifted  up  from  the  underlying  tissue, 
and  finally,  in  the  majority  of  cases,  is  torn  through,  permitting  tlio 
partial  or  complete  passage  of  the  child  into  the  peritoneal  cavity. 
The  emptied  uterus  then  contracts,  and  the  expulsive  pains  cease.  The 
conditions  which  specially  lead  to  a  dangerous  attenuation  of  the  lower 
uterine  segment  are  the  pressure  of  a  hjdrocephalifi  head,  a  neglected 
shoulder  presentation,  and  where  the  descent  of  the  child  is  hindered 
by  pelvic  contraction,  by  cicatricial  tissue  or  by  tumors  obstructing  the 
parturient  passage.  Rupture  is  favored  whenever  augmented  pressure, 
as  in  lateral  obliquity  and  anteflexion  of  the  uterus,  and  in  transverse 
presentations,  is  brought  to  bear  upon  a  limited  area  of  the  already 
overdistended  tissues. 

There  are  very  great  individual  differences  in  the  distensibility  of 
the  uterine  and  cervical  tissues.  In  Avomen  who  have  borne  many 
children,  rupture  may  occur  before  any  great  degree  of  stretching  has 
been  reached.  In  the  case  of  which  the  post-mortem  appearances  are 
given  in  Fig.  229,  spontaneous  rupture  occurred  in  the  tenth  preg- 
nancy. Labor  commenced  at  noon,  and  the  membranes,  wliich  had 
begun  to  protrude  through  the  vulva,  broke  near  midnight.  The  pains 
then  became  slow  and  feeble.  At  about  three  o'clock  in  the  morning 
sudden  collapse  occurred.  On  my  arrival,  thirty  minutes  later,  I  found 
the  pulse  scarcely  perceptible,  the  breathing  hurried,  and  the  extremi- 
ties cold.  As  the  head  was  well  down  in  the  pelvis,  I  applied  forceps, 
and  extracted  without  effort  a  dead  child  weighing  ten  and  a  half 
pounds.  Previous  to  the  collapse  the  patient  had  felt  comfortable.  At 
the  moment  of  its  occurrence  a  distinct  snapping  sound  was  heard  by 


RUPTURES  OF  THE  GENITAL  CANAL. 


613 


the  hospital  physician,  Dr.  J.  D.  Griffith,  who  sat  several  yards  distant 
from  the  bedside.  The  patient  stated  that  she  felt  a  sensation  as 
though  a  warm  fluid  was  pouring  into  the  abdominal  cavity.  As  the 
pelvis  was  ample  and  the  presentation  normal,  and  as  there  was  no 
irregularity  of  the  labor-pains,  tlie  rupture  could  only  be  accounted 


Fig.  829— Case  of  ruptured  uterus  (anterior  surface),    a,  body  of  uterus  ;  6,  ring  of  Bandl  ; 
C-,  thrombus,  shining  through  the  peritonaeum. 


for  by  assuming  a  vulnerability  of  the  uterine  tissues,  and  probably  a 
clamping  of  the  anterior  lip  between  the  head  and  the  pelvic  wall. 

On  the  other  hand,  so  great  is  the  distensibility  of  the  tissues  in 
certain  cases  that  the  foetus  may  pass  entire  from  the  uterus  into  the 
cavity  of  the  obstetrical  cervix  without  laceration  ensuing. 

Bandl  found  that  of  54G  cases  of  rupture  but  sixty-four  were  in 
primiparge.     Their  preponderance  in  multij^arae  is  for  the  most  part 


Q^^  THE  PATHOLOGY   OP  LABOR. 

the  result  of  the  laxity  of  the  round  and  lateral  ligaments  of  the 
uterus,  which  offer  accordingly  but  slight  resistance  to  the  recession 
of  the  contraction  ring ;  of  the  stretched  condition  of  the  abdominal 
parietes,  which  jjermits  obliquities  and  anteflexion  to  take  place ;  and 
■of  the  separation  of  the  recti  muscles,  which  interferes  with  the  use  of 
the  abdominal  compress. 

Of  course,  the  loss  of  vitality  over  limited  areas,  resulting  from  the 
compression  to  which  the  uterine  walls  are  frequently  subjected  in 
deformed  pelves,  enhances  the  disposition  to  rupture.  It  is  likewise 
obvious  that  the  existence  of  extreme  cervical  distention  should  not 
be  overlooked  in  cases  where  operations  are  rendered  necessary.  The 
old  prejudice  against  all  operations  within  the  uterine  cavity  while 
the  cervix  is  undilated  is  based  in  great  measure  upon  the  real  danger 
of  laceration  which  proceeds  from  the  association  in  many  cases  of  tlie 
foregoing  condition  with  difficult  labor. 

Pathological  Anatomy. — Kupture  may  occur  in  any  point  of  the 
obstetrical  cervix.  More  commonly  it  takes  place  upon  the  side. 
Owing  to  the  right  lateral  obliquity  of  the  uterus,  and  the  greater 
frequency  in  shoulder  presentations  of  head-left  positions,  the  left  side 
is  oftener  affected  than  the  right.  The  laceration  may  follow  any 
direction.  Longitudinal  tears  occur  usually  in  shoulder  presenta- 
tions, or  where  the  head  is  of  disproportionate  size ;  the  circular  rents 
are  for  the  most  part  limited  to  generally  contracted  pelves.  The 
combination  of  a  transverse  with  a  longitudinal  tear,  the  two  meeting 
at  a  right  angle,  is  not  uncommon.  It  has  been  maintained  on  theo- 
reotical  grounds  that  spontaneous  rupture  is  arrested  by  the  contraction 
ring.  This  is  certainly  the  rule  where  tiiere  has  been  no  art  interven- 
tion, but  cases  reported  by  myself  and  others  show  that  exceptionally 
the  rent  may  extend  through  the  ring  to  the  fundus  when  there 
has  been  no  interference.  When  the  uterine  walls  possess  unusual 
distensibility,  a  laceration  may  take  place  in  the  peritonaeum  while 
the  muscular  structures  remain  intact.  Again,  in  some  cases,  ow- 
ing to  an  excessive  elasticity  of  the  peritonaeum,  the  latter  does  not 
give  way  even  when  the  child  has  partially  escaped  from  the  uterine 
cavity.  These  incomplete  ruptures  are  more  likely  to  occur  upon  th(! 
sides  of  the  uterus,  at  the  site  of  the  folds  of  the  broad  ligament, 
though,  owing  to  the  relatively  loose  attachments  of  the  peritonaeum  at 
the  lower  segment,  incomplete  ruptures  are  not  necessarily  confined  to 
these  points.  The  peritoneal  wound  is  usually  more  extensive  than  the 
uterine,  but  this  rule  has  its  exceptions.  When  the  peritonaeum  is  late 
m  giving  way  the  opening  may  be  of  small  dimensions. 

Some  separation  of  the  peritoneum  from  the  underlying  structures 
is  usually  found  in  the  neighborhood  of  the  rupture.  Its  extent  is 
dependent  upon  the  degree  of  tension  to  which  the  membrane  was 
subjected  before  laceration  took  place.     At  the  body  of  the  uterus  the 


RUPTURES  OF  THE  GENITAL  CANAL.  (515 

close  connection  between  tlie  peritonaeum  and  the  externul  musculur 
layer  renders  a  separation  at  that  point  an  impossibility. 

In  the  case  represented  by  Fig.  229  the  peritoneum  was,  on  the 
other  hand,  dissected  away  anteriorly  by  effused  blood  as  far  as  the 
umbilicus.  Hfematomata  are  the  rule  in  incomplete  ruptures ;  in 
complete  ones  they  are  also  found  in  cases  where  the  peritoneum  has 
been  late  in  giving  way — i.  e.,  after  a  cavity  of  considerable  size  lias 
been  formed  by  its  detachment.  The  borders  of  the  laceration  are 
ragged.  The  body  of  the  uterus  rises  high  up  in  the  abdominal  cavity, 
and  is  inclined  to  the  side  opposite  to  that  at  which  the  rupture  has 
taken  place. 

Symptoms  and  Diagnosis. — The  occurrence  of  rupture  may  often- 
times be  foreseen  and  guarded  against  by  the  early  recognition  of  ex- 
cessive cervical  distention.  The  development  of  the  latter  is  possible 
in  any  case  of  obstructed  labor.  Unless  the  abdominal  walls  are  very 
thick,  the  boundary  between  the  firm,  hard  body  of  the  uterus  and 
the  thinned  lower  segment,  in  the  form  of  a  transverse  or  an  oblique 
furrow,  may  be  made  out  by  palpation  through  the  abdominal  walls. 
Upon  the  sides  the  round  ligaments,  even  between  the  pains,  have  the 
feel  of  tense  cords.  Usually  the  stretching  of  the  cervix  is  associated 
with  violent  pain,  with  increased  rapidity  of  pulse,  and  an  anxious 
expression  of  countenance. 

If  rupture  occurs,  the  uterus  inclines  to  the  opposite  side,  the  present- 
ing part  recedes,  and  often  vomiting^ets  in.  When  the  rupture  takes 
place  gradually,  violent  manifestations  are  exceptional.  The  pains  even 
then  may  continue,  and  force  the  foetus  into  the  abdominal  cavity. 

In  cases  of  sudden  rupture  the  pains  cease  instantly,  and  symptoms 
of  collapse  usually  make  their  appearance.*  Vomiting,  prostration,  the 
cool  skin,  the  rapid  pulse,  the  drawn  features,  all  point  to  internal 
haemorrhage  and  shock.  Blood  flows  from  the  vagina,  and  the  present- 
ing part  recedes  from  the  joelvic  brim. 

Certainty  in  diagnosis  is  reached  when  the  uterus  upon  palpation 
is  found  to  be  empty  and  the  outlines  of  the  child  can  be  made  out 
through  the  abdominal  coverings.  If  rupture  takes  place  after  the 
presenting  part  has  become  fixed  in  the  pelvis,  internal  exploration  is 
often  out  of  the  question  previous  to  the  birth  of  the  child.  Usually, 
however,  the  existence  of  the  rent  is  easily  made  out  by  the  examining 
hand. 

*I  employ  here  the  term  "usually"  because  in  one  instance  a  patient  was 
brought  to  the  Bellevue  Hospital  in  a  fairly  good  condition.  On  examination  I 
found  the  child  in  the  uterine  cavity,  but  the  head  had  receded,  and,  to  my  surprise, 
my  hand  passed  through  a  large  rent  to  the  intestines.  Winckel  (Lehrbuch  der 
Geburtshiilfe,  p.  5G3)  ascribes  sudden  symptoms  of  collapse  to  the  direct  introduc- 
tion of  large  quantities  of  poison  germs  into  the  abdominal  cavity,  whereas  in  cases 
of  traumatism  without  mycosis  the  result  depends  upon  the  suddenness  of  the  oc- 
currence and  the  quantity  of  blood  lost. 


Q^Q  THE  PATHOLOGY  OF  LABOR. 

The  passage  of  the  child  through  the  opening  into  the  abdominal 
cavity  is  usual ;  but  to  this  rule  there  are  exceptions.  I  have  seen  three 
cases,  two  complete  and  one  incomplete,  where  the  child  remained 
within  the  uterus  in  spite  of  the  existence  of  extensive  laceration. 

The  symptoms  of  incomplete  rupture  are,  at  the  time  of  its  occur- 
rence, of  less  severity  than  the  foregoing.  The  pain  and  collapse,  the 
cessation  of  uterine  contractions,  and  the  recession  of  the  presenting 
part  are  usually  absent.  Often  the  rupture  may  have  existed  for  some 
time  without  appreciable  phenomena  pointing  to  its  existence.  The 
frequent  pulse  is  the  most  constant  sign.  As  incomplete  ruptures  have 
almost  always  a  lateral  situation,  large  vessels  are  apt  to  be  injured  and 
the  internal  haemorrhage  to  be  profuse. 

In  rare  cases  subperitoneal  emphysema,  due  to  the  entrance  of  air  or 
gases  arising  from  putrefaction,  may  be  recognized  by  the  hand  or  by 
the  ear  on  the  anterior  surface  or  upon  the  sides  of  the  uterus,  and  ex- 
tending sometimes  into  the  iliac  regions. 

Treatment — Prophylaxis. — In  view  of  the  serious  prognosis  in  cases 
of  uterine  rupture,  the  question  of  prophylaxis  is  one  of  peculiar  in- 
terest and  importance.  The  outcome  of  Bandl's  demonstration  regard- 
ing the  etiology  of  the  accident  is  to  place  in  a  clear  light  the  responsi- 
bility of  the  physician  for  its  occurrence.  If  it  can  not  always  be 
foreseen  and  prevented,  there  is  no  excuse  for  the  accident  when  the 
development  of  the  recognizable  conditions  which  lead  to  it  is  over- 
looked, or  where  palpable  warnings  are  neglected. 

In  multiparte  with  contracted  pelves,  where,  as  a  consequence  of 
previous  pregnancies,  the  ligaments  are  lax  and  the  lower  segment  is 
soft  and  distensible,  it  is  desirable,  so  soon  as  the  child  is  viable,  to 
induce  premature  labor,  and  thus  to  diminish  the  disjoroportion  be- 
tween the  head  and  the  pelvis. 

If  the  conditions  described  by  Bandl  begin  to  develop  during  labor, 
lateral  obliquities  should  be  corrected,  either  by  placing  the  patient 
upon  the  side  to  which  the  presenting  part  is  turned,  or  by  fixing  the 
uterus  with  compresses  and  a  bandage  in  the  median  line.  In  hydro- 
cephalus, puncture  should  be  resorted  to  at  an  early  period. 

If  the  recession  of.  the  body  of  the  uterus  continues,  and  the  head 
is  movable,  version  should  be  performed,  provided  always  that  it  can 
be  accomplished  without  violence.  In  the  introduction  of  the  hand, 
every  pains  should  be  taken  to  correctly  appreciate  the  additional 
strain  to  which  the  cervical  tissues  are  subjected.  When  an  extremity 
has  been  seized,  and  tractions  are  made,  the  contraction  ring  which 
separates  the  body  from  the  lower  segment  interferes  alike  with  the 
descent  of  the  breech  and  the  ascent  of  the  head  into  the  fundus.  If 
rude  force  is  employed,  the  increased  pressure  that  temporarily  is  ex- 
erted upon  the  side  of  the  cervix,  which  is  bulged  by  the  presenting 
part,  can  easily  give  rise  to  rupture.     To  avoid  any  unnecessary  strain 


RUPTURES  OF   THE   GENITAL  CANAL. 


617 


during  version,  counter-pressure  should  be  made  over  the  fundus  of 
the  uterus  by  a  trained  assistant,  while  the  operator  controls  the  direc- 
tion of  the  head  by  means  of  his  free  hand  laid  upon  the  abdominal 
wall. 

If  the  head  is  fixed  in  the  pelvis,  the  forceps  is  usually  available. 
If,  however,  the  head  is  movable  and  version  contra-indicated,  the  for- 
ceps is  not  likely  to  help  the  child,  and  is  nearly  certain  to  injure  the 
mother.     In  a  few  cases  it 
is  possible  to  press  the  head 
into   the    pelvis    by   force 
exerted  with  the  two  hands 
from  above  the  pubes. 

If  craniotomy  becomes 
necessary,  Bandl  advises 
seizing  the  head  in  the 
forceps  before  using  the 
perforator,  as  even  mod- 
erate pressure  upward  in 
the  tense  state  of  the  cer- 
vix may  lead  to  laceration. 

In  neglected  shoulder 
l)resentations,  pains  should 
be  taken  to  ascertain 
whether  the  child  is  living 
before  performing  version. 
This  can  at  times  be  ac- 
complished by  passing  the 
hand     upward     near     the 

shoulder  and  feeling  for  pulsations  of  the  cord.  In  all  extreme  cases, 
the  continued  retraction  of  the  uterus,  by  limiting  the  placental  area, 
is  apt  to  produce  fetal  asphyxia.  If  the  child  is  living,  the  conditions 
are  usually  such  that  version  can  still  be  performed,  provided  care  be 
taken  at  the  same  time  to  press  the  head  from  without  toward  the 
uterine  axis.  Excessive  distention  of  the  cervix  develops  much  more 
slowly  in  primiparae  than  in  women  who  have  had  previous  confine- 
ments. If  the  child  is  dead,  or  where  version  is  impracticable,  decapi- 
tation should  be  employed  to  release  the  patient  from  further  danger. 

Treatment  after  the  Occurrence  of  Rupture. — If  rupture  is  sus- 
pected to  have  taken  place,  the  child  should  be  delivered  without  de- 
lay. The  means  of  delivery  should  be  selected  with  the  view  to  enlarge 
the  opening  as  little  as  possible.  In  vertex  presentations,  if  the  diag- 
nosis is  clear,  it  is  advisable  to  perforate  and  extract  with  the  cranio- 
clast,  as  the  child  is  rarely  born  alive  where  rupture  has  taken  2:)lace. 

If  the  head  only  has  passed  through  the  rent,  if  the  os  is  dilated, 
and  if  the  feet  are  felt  near  the  pelvic  brim,  the  withdrawal  of  the  child 


Fig.  230. 


-Retraction  in  a  case  of  shoulder  presentation. 
(Bandl.) 


g^g  THE   PATHOLOGY   OF   LA15011. 

by  version  is  usually  effected  without  difficulty.  If,  however,  the  pel- 
vic contraction  is  extreme,  if  the  cervix  is  rigid,  or  if  so  large  a  portion 
of  the  foetus  has  passed  into  the  peritoneal  cavity  that  its  withdrawal 
is  liable  to  increase  the  size  of  the  laceration,  it  is  doubtless  better  to 
incise  the  abdomen  at  the  linea  alba,  and  deliver  through  the  artificial 
opening.  There  is  not  only  less  shock,  but  the  opening  into  the  ab- 
domen enables  the  operator  to  remove  effused  blood  and  amniotic  fluid 
from  the  peritoneal  cavity.  Still,  the  not  uncommon  impression  that 
the  ruptured  uterus  furnishes  a  promising  field  for  abdominal  surgery 
does  not  take  into  account  that  in  many  of  the  cases  where  laparotomy 
is  clearly  indicated,  the  patient  is  practically  moribund.  The  employ- 
ment of  the  suture  to  close  the  uterine  wound,  in  view  of  recent  Cesa- 
rean successes,  sounds  reasonable ;  but  it  must  be  remembered  that, 
with  ragged  borders  infiltrated  with  blood,  with  the  stripping  of  the 
peritonaeum,  and  with  air  or  gases  sometimes  infiltrated  into  the  sub- 
peritoneal connective  tissue,  the  conditions  for  union  are  in  no  wise 
comparable  to  those  which  exist  when  a  clean  incision  is  made  into 
a  perfectly  normal  muscular  organ.  However,  in  the  cases  gathered 
by  Harris  for  the  United  States,  there  were  53i^  per  cent  of  recov- 
eries. 

The  supravaginal  amputation  of  the  uterus,  wiih  suture  of  the  peri- 
tonaeum below  the  ligature,  promises  fairer  results,  though  the  deep 
situation  of  the  tear  makes  it  difficult  to  secure  a  healthy  pedicle. 
Godsen  collected  seven  cases,  all  of  which  terminated  fatally,  but  more 
recently  Slavjansky,  Krassowsky-Halbertsma,  jMermann,  Fontana,  Coe, 
"VViedow,  and  Kehrer  have  each  reiwrted  a  recovery  under  seemingly 
desperate  conditions.* 

If  the  abdomen  is  opened,  even  when  hesitation  is  felt  about  the 
deep  suture  or  ablation,  there  should  be  none  concerning  the  em- 
ployment of  the  peritoneal  suture,  by  means  of  which  the  complete 
rupture  is  converted  into  an  incomplete  one  with  its  more  favorable 
prognosis. 

When  the  child  can  be  removed  by  the  natural  passages  without  an 
increase  of  the  laceration,  and  the  latter  is  confined  to  the  lower  seg- 
ment, in  all  cases  where  rupture  is  incomplete,  or  where  the  uncer- 
tainty as  to  the  extent  of  the  injury  leads  the  physician  to  shrink  from 
abdominal  section,  clots  in  the  vicinity  of  the  opening  should  be  re- 
moved by  the  hand,  firm  contractions  should  be  excited  by  manual 
pressure,  and  every  pains  should  be  taken  to  secure  by  irrigation  an 
antiseptic  condition  of  the  genital  tract. 

As  death,  when  not  due  to  shock  or  haemorrhage,  is  most  frequently 

the  result  of  septic  changes  in  the  retained  fluids,  a  priori  drainage 

ought  to  prove  an  essential  aid  to  treatment.     The  correctness  of  this 

prevision  has  been  realized  by  successes  obtained  through  its  instru- 

*  Vide  paper  by  H.  C.  Coe,  M.  D.,  Med.  Record,  Nov.  2,  1889. 


RUPTURES  OP  THE   GENITAL   CANAL.  619 

mentality  by  Frommel,*  Mosbach,  Graefe,  Felsenreic]i,t  Hecker,J  and 
Mann.*  The  plan  recommended  by  the  latter,  based  upon  the  experi- 
ence of  Gustav  Braun's  clinic,  consists  in  taking  a  large-sized  piece  of 
drainage  tubing,  and  bending  it  in  the  middle,  so  as  to  leave  the  ex- 
tremities of  equal  length.  A  large  opening  should  then  be  made  at  the 
arch,  which  is  to  be  introduced  through  the  point  of  rupture,  and  the 
descending  branches  of  the  tube  should  be  fastened  together  to  prevent 
the  formation  of  a  bridge  of  tissue  between  them  during  the  process 
of  healing.  The  upper  end  of  the  drainage  apparatus  should  be  passed 
from  a  half-inch  to  an  inch  beyond  the  torn  borders  of  the  uterine 
wound,  and  the  lower  ends  stitched  with  silk  to  the  posterior  commis- 
sure. Over  the  vulva  and  the  apparatus  there  should  be  placed  an 
antiseptic  dressing,  which  should  be  changed  several  times  daily.  After 
the  first  four  or  five  days,  by  which  time  it  may  be  assumed  that  pro- 
tective adhesions  will  have  formed  in  the  neighborhood,  a  regular  irri- 
gation of  the  wound  with  a  two-per-cent  solution  of  carbolic  acid 
should  be  carried  out,  with  a  view  to  prevent  a  septic  poisoning  from 
the  decomposition  of  the  pus  and  the  lochia. 

More  recently,  in  the  discussion  before  the  Geburtshiilflich  Gynaekolo- 
gischen  Gesellschaft,||  of  Vienna,  it  was  recommended  to  secure  drain- 
age, either  as  above,  by  rubber  tubing,  or  by  means  of  lamp  wicking 
(fifty  threads)  prepared  with  iodoform,  while  the  vagina  was  loosely 
packed  with  iodoform  gauze.  Drainage  should  be  sujiported  by  every 
means  calculated  to  maintain  uterine  contractions  and  check  haemor- 
rhage. These  objects  are  best  secured  by  manual  compression  of  the 
uterus,  either  with  or  without  conjoined  pressure  of  the  aorta,  to  be 
continued  if  necessary  for  hours.  Before  leaving  the  patient  a  grad- 
uated compress  should  be  placed  around  the  uterus,  to  maintain  firm 
uterine  contractions,  or,  what  I  regard  as  preferable  in  these  and  analo- 
gous cases,  a  rubber  water-bag,  which  adjusts  itself  to  the  contour  of 
the  uterus  and  is  hardly  less  effective  than  the  hand  itself. 

In  the  Vienna  discussion  alluded  to  Dr.  Fleischman  stated  that  in 
eighteen  cases  of  anterior  rupture,  five  of  which  had  been  treated  by 
drainage,  all  died ;  whereas,  of  fourteen  cases  of  posterior  rupture,  of 
five  treated  by  drainage  all  recovered. 

In  certain  of  the  reported  cases  of  recovery  where  drainage  was  eni- 

*  Frommel.  Zur  Aetiologie  unci  Therapie  der  Utenisruptur,  Ztschr.  f.  Geburtsh. 
und  Gynaek.,  Bd.  v.  Heft  2. 

t  Pelsexreich,  Beiti-ag  zur  Therapie  der  Uterusriijitur,  Arch.  f.  Gynaek.,  Bd. 
xvii,  Heft  3. 

t  Hecker.  Centralblatt  f.  Gynaek..  1881.  No.  x, 

*  Manx,  Centralblatt  f .  Gynaek..  1881,  No.  xvi.  Drainage  in  the  cases  referred 
to  was  employed  in  complete  as  well  as  in  incomplete  ruptures.  The  triumph  of 
the  principle  of  drainage  is  best  demonstrated  by  the  fact  that  in  most  of  the  cases 
gastrotomy  was  contra-indicated  by  reason  of  excessive  shock. 

II  Sitzung's  Berichte,  1888,  No.  9. 


620 


THE   PATHOLOGY   OF   LABOR. 


ployed  an  opening  was  let  in  the  nterine  wall  commnnicating  with  an 
adjacent  sac  formed  eitlier  by  the  folds  of  the  broad  ligament  or  by 
false  membranes  which  persisted  after  the  removal  of  the  dressings. 

Rupture  limited  to  the  Peritoneal  Covering:  of  the  Uterus.— This 
very  rare  form  requires  but  brief  mention.  In  all  but  ten  cases  have 
been  reported.  It  occurs  nnder  apparently  normal  conditions,  without 
premonitory  symptoms.  It  is  supposed  to  be  due  to  deficient  elasticity 
of  the  peritonaeum,  and  may  take  place  during  either  pregnancy  or 
labor.  Death  in  the  known  cases  resulted  from  internal  hoemorrhage, 
from  peritonitis,  or  from  shock  (Spiegelberg). 

Perforation  from  Pressure.— In  stud}'ing  the  influence  of  the  con- 
tracted pelvis,  we  have  already  had  occasion  to  consider  the  origin  of 
circumscribed  losses  of  substance  in  the  uterus  due  to  the  pressure  of 
the  pelvic  walls.  In  the  present  connection  it  is  only  necessary  to  state 
that  they  are  more  frequently  followed  by  recovery  than  the  ruptures, 
in  favorable  cases  exudation  closing  the  opening  and  the  necrosed  tissue 
passing  away  through  the  vagina. 

Lacerations  of  the  Vaginal  Portion  of  tlie  Cervix. — Lacerations  at 
the  OS  externum  of  moderate  extent  are  the  nearly  constant  concomi- 
tant of  physiological  labor.  The  "  show  "  of  monthly  nurses  consists 
of  mucus  tinged  with  blood  furnished  from  the  slight  tears  which  are 
produced  during  the  passage  of  the  head  through  the  cervical  orifice. 
At  times,  however,  these  lacerations  may  assume  a  pathological  impor- 
tance, reaching  upward  to  the  vaginal  junction,  or  even,  in  extreme 
cases,  stretching  outward  through  the  upper  portion  of  the  vagina. 
At  the  time  of  their  occurrence,  they  give  rise  to  no  special  symptoms. 
After  the  birth  of  the  child,  they  may  become  the  source  of  post-jyar- 
tmti  haemorrhage,  or  they  may  interfere  with  involution,  and  during 
childbed  expose  the  patient  to  the  risks  of  infection.  In  after-life  they 
furnish  the  foundation  of  a  multitude  of  uterine  disorders  (Emmet). 
They  occur  most  frequently  in  primiparae,  especially  elderly  ones ;  in 
oedema  of  the  cervix ;  in  cases  where  the  anterior  lip,  pushed  downward 
by  the  occiput,  is  caught  between  the  head  and  tlie  pubic  walls,  and 
thus  is  prevented  from  retracting  simultaneously  with  the  posterior 
lip  ;  and  as  a  consequence  of  obstetrical  operations.  Severe  lacerations 
extending  above  the  vaginal  junction  are  most  frequently  produced  in 
pelvic  deliveries,  where  the  head  is  extracted  by  force  through  an  imper- 
fectly dilated  os. 

Most  commonly  these  lacerations  follow  a  longitudinal  direction. 
In  rare  cases,  where  there  is  extreme  rigidity  of  the  os  externum,  or 
where,  after  the  escape  of  the  amniotic  fluid,  the  head  distends  the  an- 
terior lip  without  pressing  upon  the  os,  a  transverse  rent  may  occur 
through  which  the  child  may  pass.  Sometimes  a  longitudinal  tear  may 
be  combined  with  one  running  transversely,  the  lip  then  hanging  by  a 
pedicle  to  the  uterus,  or  the  entire  lip  may  be  torn  off.     Isolated  cases 


RUPTURES  OF   THE   GENITAL   CAXAL.  621 

of  so-called  annular  laceration  have  been  reported,  where  the  transverse 
rent  has  extended  through  the  whole  vaginal  portion,  so  that  the  lower 
segment  has  been  detached  in  the  form  of  a  ring.  In  these  cases  hsem- 
orrhages  very  rarely  if  ever  occur. 

In  addition  to  the  ordinary  principles  which  should  govern  the 
management  of  every  labor,  Bandl  lays  great  stress  upon  the  pushing 
up  of  the  confined  anterior  lip  as  an  important  prophylactic  measure. 

Haemorrhage  due  to  cervical  laceration  should  be  controlled  by  clos- 
ing the  rent  with  silver  or  catgut  sutures.  In  view  of  the  bad  light  by 
which  the  operation  has  usually  To  be  performed,  the  suggestion  of 
Schroeder,  to  draw  the  cervix  with  the  volsella  forceps  outside  the  vulva, 
while  an  assistant  pushes  the  uterus  down  into  the  jDelvis  from  above,  is 
worthy  of  being  borne  in  mind.  With  the  wounded  parts  thus  exposed, 
the  reparative  operation  advocated  presents  scarcely  appreciable  difficul- 
ties to  even  the  least  surgical  of  attendants. 

If  no  hemorrhage  occurs,  cervical  lacerations  are  rarely  recognized 
except  by  physicians  who  take  pains  to  invariably  investigate  the  j^ost- 
partum  condition  of  every  patient.  As  a  rule,  with  strict  antisepsis 
they  heal  rapidly  during  involution.  Nevertheless,  it  is  my  present  cus- 
tom to  close  all  extensive  lacerations  with  a  continuous  catgut  suture. 
After  the  expulsion  of  the  placenta  the  operation  is  easy,  is  devoid 
of  risk,  and  is  followed  by  speedy  union  of  the  torn  surfaces.  For 
the  gynaecological  expert  Veit  recommends  the  passage  of  the  sutures 
without  the  aid  of  the  speculum,  by  the  touch  alone.  This  he  accom- 
plishes by  means  of  a  needle  seized  at  right  angles  with  a  long-handled 
needle  holder.  The  needle  he  passes  first  through  the  anterior,  and 
then  through  the  posterior  lip,  under  the  guidance  of  two  fingers  of 
the  left  hand,  while  the  fundus  is  depressed  by  an  assistant  from  above. 
Traction  upon  the  first  suture  materially  aids  in  the  introduction  of  the 
others. 

Lacerations  of  the  Vagina. — Vaginal  lacerations  vary  in  gravity 
according  to  their  extent  and  position.  In  the  upper  part  of  the  canal 
they  are,  as  a  rule,  continuous  with  ruptures  begun  in  the  uterus 
or  in  the  vaginal  portion.  In  contracted  pelves,  where,  owing  to 
excessive  retraction,  the  head  fills  the  vagina  without  entering  the 
pelvic  brim,  isolated  lacerations  of  the  vagina  may  follow  the  same 
general  causes  as  those  which  give  rise  to  rupture  of  the  uterus.  Per- 
haps the  most  common  vaginal  lesion  is  that  produced  by  the  un- 
guarded blades  of  the  forceps  when  applied  diagonally  in  j)lace  of 
directly  to  the  sides  of  the  child's  head. 

In  the  lower  portion  of  the  canal  these  lacerations  heal  speedily 
without  serious  symptoms,  provided  cleanliness  be  maintained  from  the 
first.  Lacerations  of  the  fornix  only  are  of  great  importance  on  ac- 
count of  their  proximity  to  the  peritonaeum,  and  because  of  the  exposure 
of  the  parametrium  to  septic  absorption.    The  immediate  closure,  there- 


g22  THE   PATPIOLOGY  OF  LABOR. 

fore,  of  these  rents  with  silver  sutures  ought  to  be  attempted.  Owing 
to  the  laxity  of  tlie  tissues,  the  difficulties  of  reaching  the  wound  are 
not  excessive,  while  the  dangers  to  be  forestalled  are  of  a  peculiarly 
threatening  character. 

The  orio'in  and  nature  of  fistulous  communications  with  the  blad- 
der and  the  rectum  have  already  been  considered  in  connection  with 
the  pathology  of  labor.  Eesulting  for  the  most  part  from  necrosis 
due  to  pressure,  they  are  rarely  the  immediate  sequela?  of  childbirth, 
the  sloughing  of  the  dead  tissue  taking  place  during  the  course  of  the 
puerperal  period.  The  treatment  in  such  cases  belongs  properly  to 
the  domain  of  gynaecology.  The  closure  by  suture  is  only  available  as 
a  plan  of  treatment  in  cases  where  complete  laceration  through  the 
tissues  into  the  neighboring  organs  takes  place  during  labor,  as  the 
consequence  of  rudely  performed  obstetrical  operations. 

Lacerations  of  the  Vaginal  Orifice.— Owing  to  the  small  size  of  the 
vaginal  orifice,  tears  through  the  mucous  membrane  and  erosions  of 
the  vulva,  and,  in  primiparge,  the  rupture  of  the  frenulum,  are  to  be 
accounted  as  the  almost  inevitable  consequences  of  childbirth.  They 
are  the  principal  cause  of  the  external  soreness  experienced  after  labor. 
In  healthy  localities  they  heal  rapidly,  and  are  of  but  trivial  impor- 
tance. Of  greater  moment  are  deep  perineal  lacerations  and  those  of 
the  vestibulum. 

Lacerations  of  the  Vestibulum. — Tears  limited  to  the  mucous  mem- 
brane are  usually  found  after  labor  at  the  sides  of  the  clitoris.  In 
exceptional  cases  these  tears  may  involve  the  underlying  erectile  tissue 
(bulbs  of  the  vestibule),  and  become  the  source  of  profuse  or,  when 
overlooked,  even  of  fatal  haemorrhage.  The  blood,  which  may  be 
either  venous,  arterial,  or  of  mixed  origin,  spurts  in  jets  or  oozes  as 
from  a  soaked  sponge.  The  recognition  of  the  lesion  is  easy  upon 
inspection.  It  should  always  be  thought  of  as  a  possible  cause  of  post- 
partum haemorrhage  in  every  case  where  the  flow  continues  after  the 
contraction  of  the  uterus. 

The  bleeding  may  be  temporarily  arrested  by  pressing  the  tissues 
with  the  finger  against  the  inner  surface  of  the  pubic  bones  until 
the  expulsion  of  the  placenta.  Ligatures  to  the  bleeding  vessels, 
owing  to  the  complexity  of  the  structures,  are  of  no  avail.  In  slight 
cases  a  stream  of  cold  water  is  a  sufficient  haemostatic.  In  others, 
the  bleeding  requires  to  be  checked  by  one  or  two  deep  sutures 
introduced  so  as  to  bring  the  torn  surfaces  into  apposition.  If  the 
bleeding  appears  to  come  from  one  or  two  points,  the  jiinccx  liemosta- 
tiqnes  are  of  service.  Styptics  and  astringents  are  usually  effective, 
but  they  possess  the  drawback  of  augmenting  the  pain  and  soreness. 

Lacerations  of  the  Perinaeum.— In  the  chapter  upon  the  :Manage- 
ment  of  Normal  Labor,  the  nature,  origin,  and  prevention  of  perineal 
lacerations  have  already  been  considered.     The  diagnosis  is  made  by  a 


RUPTURES  OF   THE  GENITAL  CANAL.  623 

careful  inspection  of  the  genital  organs  after  delivery.  The  extent  of 
the  lesion  is  estimated  by  including  the  recto-vaginal  septum  between 
the  thumb  and  index-finger. 

The  treatment  of  perineal  laceration  consists  either  in  keeping  the 
woman  in  bed  until  the  wounded  surfaces  cicatrize,  or  in  bringing  the 
parts  into  apposition  by  means  of  sutures,  with  the  intent  to  secure 
primary  union.  The  first  plan  is  sufficient  if  the  wound  be  of  slight 
extent.  If,  however,  the  rupture  extends  to  the  sphincter  ani,  and 
involves  the  entire  perineal  body,  the  vagina  is  left  without  support, 
rectocele  or  cystocele  ensues,^ the  uterus  sinks  downward  and  becomes 
displaced  backward,  and  in  the  end  prolapsus  is  apt  to  result.  If  the 
sphincter  ani  and  the  recto-vaginal  wall  are  involved,  inability  to  re- 
strain the  bowels  adds  to  the  discomfort  of  the  patient.  This  sequence 
of  symptoms,  so  familiar  to  gyngecologists,  forms  an  urgent  plea  for 
the  resort  to  surgical  means  to  repair  the  injury.  Only  a  very  credu- 
lous j)erson  really  believes  that  he  has  witnessed  union  by  first  inten- 
tion in  extensive  ruptures,  as  the  result  of  tying  the  knees  together 
and  enjoining  rest  upon  the  side.  The  action  of  the  transversi-peri- 
naei  muscles  tends  to  draw  the  torn  surface  apart.  Moreover,  the 
necessity  of  separating  the  knees  in  passing  urine,  and  to  enable  the 
nurse  to  cleanse  the  genitalia,  makes  it  impossible  to  keep  them  in 
contact  for  any  lengthened  period. 

To  the  immediate  operation  there  is  no  valid  objection.  It  is  not 
difficult,  it  is  not  extremely  painful,  and  its  performance,  as  a  rule, 
diminishes  the  risks  of  infection  and  shortens  the  puerperal  period.  It 
is  true  that  the  object  aimed  at  may  not  be  attained.  If  labor  has  been 
conducted  in  accordance  with  antiseptic  principles,  if  no  syphilis  ex- 
ists, and  the  vitality  of  the  tissues  has  not  been  impaired  by  cedema  or 
long-continued  pressure,  failure  is  the  exception.  The  argutnent  that 
the  operation  is  in  itself  a  confession  does  not  deserve  discussion. 

For  its  performance  the  patient  should  lie  upon  her  back,  with  her 
hips  well  over  the  edge  of  the  bed.  Two  assistants  to  hold  the  knees 
are  of  great  convenience.  In  ojjerations  requiring  the  introduction  of 
not  more  than  three  or  four  sutures  angesthesia  may  be  dispensed 
with.  In  lengthy  operations,  such  as  are  necessitated  by  lacerations 
extending  up  the  posterior  vaginal  wall,  ether  should  be  given  in  place 
of  chloroform,  and  its  administration  should  be  intrusted  to  an  experi- 
enced person  only.  It  can  not  be  too  often  repeated  that  anaesthesia 
after  labor  calls  for  the  exercise  of  extreme  caution. 

The  wound  should  be  prepared  by  carefully  washing  away  blood 
and  clots  with  warm  carbolized  water.  For  lacerations  not  extending 
through  the  sphincter  ani  I  use  Peaslee's  needle,  which  is  furnished 
with  an  eye  at  the  point,  and  is  set  in  a  wooden  handle.  It  possesses 
the  advantage  of  strength,  a  quality  of  no  mean  importance  in  making 
the  circuit  of  the  redundant  tissues  with  which  we  have  to  deal  after 


624 


THE  PATHOLOGY  OP  LABOR. 


labor.  I  use  the  silver  suture,  and  after  repeated  trials  have  not  been 
able  to  convince  myself  that  it  can  be  equally  well  replaced  by  silk. 

The  first  suture  should  be  passed  just  in  front  of  the  anus.  It 
should  be  entered  and  brought  out  about  a  half -inch  from  the  rupt- 
ured borders.  The  others  should  follow  at  from  one  third  to  one  half 
inch  intervals.  Each  suture  should  make  the  entire  circuit  of  the 
wound.  This  can  be  readily  accomplished  by  guiding  the  point  of  the 
needle  through  the  residue  of  the  perineal  body  Avith  two  fingers  in  the 
anus  and  with  the  thumb  upon  the  vaginal  surface.  To  secure  a 
stronger  hold  for  the  last  suture,  the  needle  should  be  made  to  enter 
the  vagina  above  the  upjjer  angle  of  the  rent,  and  the  wire  should  be 
made  to  traverse  a  portion  of  undenuded  tissue  before  completing  the 
circuit.  In  closing  the  wound,  great  pains  must  be  taken  not  to  twist 
the  sutures  too  tightly,  as  in  that  case  they  are  apt  either  to  cut  out  or 
to  produce  sloughing. 

Sometimes,  in  rents  extending  through  the  sphincter  ani  and  the 
recto-vaginal  septum,  the  simple  perineal  sutures  will  effect  a  satisfac- 
tory union.  Thus,  in  a  patient  at  the  Emergency  Hospital,  with  a 
laceration  extending  nearly  to  the  cervix,  and  whose  condition  pre- 
cluded a  lengthy  operation,  I  obtained  an  excellent  result  by  passing  a 
single  wire  above  the  angle  of  the  wound,  and  twisting  the  ends  out- 
side the  perineum.  As  a  rule,  however,  it  is  desirable  to  adjust  the 
edges  with  great  care,  first  closing  the  rent  upon  the  rectal  side,  then 
bringing  together  the  split  in  the  mucous  membi'ane  upon  the  vaginal 
side  with  transverse  sutures,  and  finally  bringing  the  lower  borders  of 
the  perinaeum  together  by  a  separate  operation.  This  disposition  is 
the  so-called  triangular  suture  of  Simon.*  It  requires  fine  needles,  a 
needle-holder,  an  adjuster,  a  wire-twister,  and,  in  fact,  all  the  para- 
phernalia of  the  gynecologist.  The  length  of  the  operation  renders 
necessary  an  anaesthetic,  which  should  be  ether  rather  than  chloro- 
form. The  disgusting  condition  of  a  patient  with  laceration  through 
the  recto-vaginal  septum,  where  the  healing  process  has  been  the  result 
of  granulation,  justifies  the  attempt  to  secure  immediate  union. 

The  requirements  in  the  way  of  after-treatment  are  very  simple. 
The  urine  should  be  drawn  every  four  to  six  hours  with  a  catheter, 
until  the  patient  is  able  to  pass  her  water  spontaneously ;  the  bowels 
should  be  kept  open  with  salines ;  and  the  knees  should  be  tied  loosely, 
to  remind  the  woman  of  the  desirability  of  keeping  them  in  contact. 
The  wound  should  be  kept  scrupulously  clean.  Whenever  urine  has 
been  passed  the  perineum  should  be  washed  with  warm  carbolized 
water,  then  dried,  and  sprinkled  with  iodoform.  Pads  of  iodoform 
gauze  should  be  placed  to  the  sides  of  the  sutures  to  prevent  them 
from  causing  ulceration  of  the  adjacent  soft  parts.     A  little  opium 

*  Vide  Garrigues's  excellent  paper  entitled  The  Ob.stetric  Treatment  of  the 
Permsura,  Am.  Jour,  of  Obstet.,  April,  1880. 


RUPTURES   OF   THE   GENITAL   CAXAL.  ^25 

may  be  given,  if  the  pain  experienced  is  considerable.  Pain  in  child- 
bed from  any  cause  helps  to  depress  the  vitality.  The  perineal  sutures 
should  be  left  a  week  in  situ.  Many  ^Jromising  cases  are  spoiled  by 
removing  the  sutures  too  early.  The  vaginal  sutures  may  be  allowed 
to  remain  until  the  external  union  is  sufficiently  solid  to  permit  the 
introduction  of  the  speculum.  Catgut  sutures  for  the  rectum  are  to 
be  preferred  when  they  can  be  obtained  of  good  quality,  as  they  obviate 
the  necessity  of  future  removal. 

For  the  more  superficial  lacerations  of  the  perineum  the  serves 
fines  invented  by  Vidal  de  Cassis,  and  extensively  used  in  Vienna,  have 
been  warmly  advocated  in  this  country  by  Professor  M.  D.  Mann,*  and 
by  Garrigues.f  My  own  experience  with  them  has  not  been  fortu- 
nate ;  but  the  better  results  from  their  use  in  the  hands  of  their  sup- 
porters recommend  them  to  trial. 

Thrombus  of  the  Vagina  and  Vulva. — Hfemorrhagic  effusions  into 
the  external  organs  of  generation  occur  with  greatest  frequency  in  the 
labia  majora,  more  rarely  in  the  labia  minora,  and  occasionally  be- 
tween the  superficial  and  median  fasciae  of  the  perineum.  These  ex- 
travasations may  form  tumors  beneath  the  subcutaneous  or  submucous 
tissues  of  the  vulva  or  vagina,  which  vary  in  size  from  that  of  a  hen's 
egg  to  that  of  a  child's  head.  As  a  rule,  the  blood  is  poured  out  into 
the  cellular  tissue  seated  below  the  diaphragm  of  the  pelvis.  The  ex- 
travasation may,  however,  stretch  upward  along  the  vagina  to  the  cel- 
lular tissue  of  the  uterus,  then  posteriorly  beneath  the  peritoneum  to 
the  kidneys,  and  around  in  front  to  the  navel  and  laterally  to  the  iliac 
fossae  (Winckel).  The  source  of  the  hasmorrhage  may  be  venous  or 
arterial.  The  vessel  from  which  the  hsemorrhage  takes  place  is  usu- 
ally situated  in  the  lower  portion  of  the  vagina ;  in  less  frequent  cases, 
in  the  vulva. 

Symptoms. — The  first  sensation  experienced  at  the  time  of  the 
rupture  is  usually  one  of  intense  pain,  proportioned  to  the  size  of  the 
tumor  and  the  rapidity  of  its  formation,  though  in  a  case  witnessed 
by  Professor  Barker  J  this  symptom  was  absent.  As  the  effusion  con- 
tinues, swelling  of  the  vulva,  usually  upon  one  side,  results,  and  the 
skin  becomes  blue  and  nearly  translucent.  The  patient  complains  of 
pain,  and  feels  faint,  while  her  lips  and  cheeks  grow  white.  If  the 
sac  contains  fluid  blood,  fluctuation  is  detected ;  after  coagulation  the 
tumor  has  a  soft,  boggy  feel.  If  the  tension  increases,  the  skin  may 
yield,  the  blood  and  coagula  escape,  and,  if  no  means  be  adoj^ted  to 
arrest  the  hemorrhage,  the  patient  may  die  in  a  few  minutes  from 
acute  anemia. 

If  the  thrombus  be  of  small  size  and  situated  low  down,  the  after- 

*  Manx,  The  Immediate  Treatment  of  Superficial  Rupture  of  the  Perinaeum, 
Am.  Jour,  of  Obstet.,  November,  1874. 

f  Garrigues,  Ioc.  cit.  %  Barker,  Puerperal  Diseases,  p.  58. 

40 


Q2Q  THE  PATHOLOGY  OF  LABOR. 

symptoms  may  be  of  slight  importance.  The  fluid  may  be  absorbed, 
the  walls  of  the  cavity  unite,  and  the  tumor  disappear  entirely.  Tu- 
mors of  larger  size  produce  symptoms  referable  to  pressure,  such  as 
back-ache,  rectal  obstruction,  and  ischuria.  The  vagina  may  be  so 
narrowed  as  scarcely  to  permit  the  passage  of  the  finger.  Rupture,  if 
not  immediate,  usually  occurs  spontaneously  in  the  course  of  a  few 
days,  and  is,  as  a  rule,  preceded  by  necrosis  of  a  portion  of  the  de- 
tached mucous  membrane.  The  most  frequent  point  of  spontaneous 
rupture  is  at  the  junction  of  the  larger  and  smaller  labium.  If  the 
necrosed  tissues  become  gangrenous,  death  from  septicemia  may  result. 
Winckel  *  sums  up  the  various  terminations  of  thrombus  as  follows : 
1.  Death  from  hsemorrhage,  with  or  without  precedent  rupture;  2. 
Death  from  decomposition  of  the  sac  contents,  with  consecutive  sep- 
ticemia or  septico-pyagmia,  most  frequently  after  rupture  or  opening 
of  the  sac ;  3.  Eupture  and  recovery ;  4.  Rupture,  with  formation  of 
fistula? ;  5.  Absorption  without  rupture,  followed  by  recovery. 

Diagnosis. — The  diagnosis  is  simple.  The  rapid  development  and 
increase  of  the  tumor,  its  bluish  color,  its  elastic  or  fluctuating  char- 
acter, the  sharp  pain,  and  the  acute  anaemia,  occurring  independently 
of  uterine  hemorrhage,  sufficiently  point  to  a  sanguineous  effusion 
into  the  subcutaneous  cellular  tissue.  The  extent  of  the  tumor  must 
be  determined  by  rectal  and  vaginal  exploration.  It  is  only  at  the 
begmuing  that  it  will  be  found  possible  to  ascertain  the  seat  of  the 
hemorrhage,  whether  in  the  vulva,  vagina,  or  perineum.  Sometimes, 
after  rupture  and  the  discharge  of  the  clots,  the  bleeding  vessel  may 
be  detected. 

Etiology. — The  formation  of  the  thrombous  tumor,  with  rare  excep- 
tions, takes  place  during  or  shortly  after  labor.  If  the  vessel  rupture 
in  advance  of  the  presenting  part,  the  effusion  may  be  immediate  and 
furnish  an  obstacle  to  delivery,  or  the  descent  of  the  foetus  may  check 
the  hemorrhage  for  a  time,  to  break  out  afresh  after  the  labor  is  ended. 
In  rupture  due  to  necrosis  consequent  upon  pressure,  the  hemorrhage 
does  not,  of  course,  take  place  until  sloughing  occurs.  Rupture  may 
follow  excessive  straining,  rapid  dilatation  of  the  genital  canal,  or  direct 
injuries.  A  varicose  condition  of  the  veins  does  indeed  create  a  pre- 
disposition to  rupture,  but  is  by  no  means  a  frequent  factor  in  the  pro- 
duction of  the  accident.  Thus,  it  was  present  in  but  six  of  the  fifty 
cases  collected  by  Winckel. 

Prognosis. — The  prognosis  of  vaginal  thrombus  is  serious.  Deneux 
reported  twenty-two  deaths  in  sixty  cases,  a  mortality  evidently  ex- 
cessive ;  Winckel  reported  six  deaths  in  fifty  cases ;  Barker  reported 
two  deaths  in  twenty-two  cases;  and  Scanzoni  one  death  in  fifteen 
cases.  But  statistics  like  these  are  apt  to  give  rise  to  a  misleading 
impression.  A  thrombus  |jer  se  is  rarely  a  dangerous  complication.  It 
*  WixcKEL,  Die  Pathologic  unci  Therapie  des  Wochenbetts,  2te  Auflage,  p.  132. 


RUPTURES  OP  THE  GENITAL  CANAL.  G27 

may,  however,  become  so  either  because  after  rupture  no  means  are 
adopted  to  limit  the  amount  of  haemorrhage,  or  because,  in  unhealthy 
localities,  the  tense  membrane  covering  the  tumor  is  liable  to  become 
gangrenous,  and  the  vast  vaginal  wound  furnishes  at  once  a  congenial 
soil  for  the  multiplication  of  septic  germs,  and  an  absorbent  surface 
by  which  the  septic  poison  generated  is  afforded  a  ready  entry  into 
tiie  adjacent  cellular  tissue.  Thus,  Barker  reports  nine  cases  in  pri- 
vate practice,  in  all  of  which  the  patients  recovered.  Of  thirteen 
cases  in  hospital  practice,  two  patients  died  of  puerperal  fever.  The 
prognosis  is  likewise  less  favorable  in  cases  where  there  exists  at  the 
same  time  extensive  separation  of  the  peritonseum. 

Treatment. — The  conditions  of  successful  treatment  are  restriction 
of  the  haemorrhage  and  the  prevention  of  septicaemia.  Early  recogni- 
tion of  the  accident  is  very  desirable. 

So  soon  as  effusion  is  recognized  the  forceps  should  be  applied,  and 
the  head  should  be  extracted  as  sjieedily  as  is  consistent  with  the 
preservation  of  the  integrity  of  the  maternal  tissues.  To  quote  from 
Professor  Barker's  excellent  treatise :  "  The  exciting  cause  of  the  acci- 
dent is  the  arrest  of  the  circulation  by  the  mechanical  pressure  of  the 
presenting  part  of  the  foetus.  The  sooner  the  pressure  is  removed, 
the  sooner  the  danger  will  be  over  and  the  less  will  be  the  injury  to 
t!ie  parts."  Moreover,  as  we  have  seen,  the  head  in  its  descent  acts  as 
a  tampon,  by  means  of  which  the  haemorrhage,  whether  external  or 
in  the  submucous  tissue,  is  temjiorarily  held  in  check.  If  the  tumor 
in  advance  of  the  head  is  so  large  that  the  delivery  can  not  be  accom- 
plished Avithout  impairing  the  vitality  of  the  sac-walls,  the  danger 
should  be  averted  by  incising  the  thrombus  and  turning  out  the 
coagula. 

Haemorrhage  after  the  birth  of  the  child  is  apt  to  be  very  profuse, 
especially  if  the  sac  has  been  opened  either  by  spontaneous  rupture  of 
its  coverings  or  with  the  knife.  So  long  as  the  sac-walls  are  intact,  the 
pent-up  blood  exercises  a  considerable  pressure  upon  the  bleeding  ves- 
sel. For  this  reason  it  is  well  to  cover  an  opening,  if  one  hapijens  to 
have  formed,  with  lint  soaked  in  a  solution  of  one  of  the  per-salts  of 
iron.  The  continuance  of  internal  haemorrhage  should  then  be  checked 
by  means  of  a  water-bag  (a  large  Barnes  dilator  will  suffice)  intro- 
duced into  the  vagina  and  distended  with  ice-water.  The  hydrostatic 
pressure  rarely  requires  to  be  maintained  for  longer  than  half  a  day, 
during  which  time  it  should  be  repeatedly  removed  for  a  few  moments 
to  allow  the  vagina  to  be  cleansed  by  disinfectant  injections.  The 
urine  should  be  drawn  with  a  catheter  during  the  first  forty-eight 
hours,  as  every  straining  effort  is  to  be  carefully  guarded  against.  A 
tamjion  of  linen  rags,  or  of  cotton,  is  inadmissible  on  account  of  the 
tendency  it  possesses  to  excite  rapid  decomposition  in  the  lochial  dis- 
charges.    Immediate  opening  of  the  thrombus,  followed  by  em]] tying 


g28  THE  PATHOLOGY  OF  LABOR. 

the  sac  and  filling  the  cavity  with  lint  soaked  in  astringent  solutions, 
are  measures  which  should,  on  account  of  the  suppuration  likely  to  be 
thereby  excited,  be  reserved  for  cases  v/here  milder  procedures  have 
proved  ineffective. 

The  ultimate  opening  of  the  sac,  after  the  hemorrhage  has  once 
been  arrested,  is  rarely  to  be  avoided.  Still,  cases  are  on  record  where 
tumors  the  size  of  a  man's  fist  have  disappeared  by  absorption.  As 
this  is  the  most  favorable  mode  of  termination,  every  effort  should  be 
made  to  secure  such  a  result.  To  this  end  quiet  should  be  enjoined, 
cold  should  be  employed,  and  pain  should  be  subdued  by  opiates.  If, 
however,  the  tumor  increases  in  size,  the  skin  becomes  greatly  dis- 
colored, and  vesicles  form  upon  its  surface,  it  is  better  to  anticipate 
threatened  gangrene  or  rupture  by  incision.  If  the  circumstances  per- 
mit of  delay,  it  is  better  to  wait  three  to  four  days  to  make  sure  of  the 
stoppage  of  bleeding.  The  best  point  for  laying  open  the  tumor  is 
upon  the  inner  surface  of  the  labium  majus.  The  incision  should  be 
two  to  three  inches  in  length.  After  turning  out  the  clots  the  cavity 
should  be  irrigated  with  a  bichloride  solution  (1  to  3,000)  and  should 
then  be  packed  with  iodoform  gauze. 

Rupture  of  the  Pelvic  Articulations.* — Rupture  of  the  pelvic  ar- 
ticulations may  take  place  spontaneously  where  either  inflammation  or 
excessive  relaxation  of  the  joints  exists  at  the  time  of  labor.  More 
commonly  it  is  the  result  of  difficult  forceps  operations  performed  in 
cases  of  contracted  pelves.  The  risk  of  the  occurrence  of  this  accident 
is  especially  great  when  the  forceps  is  applied  to  the  head  at  the  brim 
and  forcible  tractions  are  made  in  a  direction  anterior  to  the  pelvic  axis. 

The  symphysis  is  the  articulation  which  is  principally  exposed  to 
this  form  of  injury,  though  it  is  obvious  that  no  increase  in  the  capa- 
city of  the  pelvis  consequent  upon  the  separation  of  the  symphysis  is 
possible  without  simultaneous  rupture  of  at  least  one  of  the  sacro-iliac 
synchondroses.  At  the  symphysis  the  rupture  is  apt  to  be  complete, 
at  the  synchondroses  the  rupture  is  usually  confined  to  the  anterior 
surface.  It  may  take  place  in  the  median  line,  or  upon  the  side,  be- 
tween the  cartilage  and  the  pubic  bone.  If  the  injury  be  slight,  the 
synovial  cavity  of  the  symphysis  may  not  be  injured.  At  the  synchon- 
droses, opening  of  the  joint-cavity  is  inevitable.  An  excessive  degree 
of  the  lesion  is  accompanied  by  laceration  of  the  vagina,  the  bladder, 
and  the  intervening  connective  tissue. 

Occasionally  the  rupture  of  the  joint  is  announced  by  a  perceptible 
sound,  by  intense  pain,  and,  as  the  result  of  the  increase  in  the  pelvic 
space,  by  rapid  advance  of  the  head.  In  the  lighter  forms,  however, 
which  make  up  the  bulk  of  the  cases  witnessed,  there  are  no  distinct- 

*  Ahlfeld,  Die  Verletzungen  der  Beckengelenke  wahrend  d.  Geburt  ui^d  im 
Wochenbett,  Schmidt's  Jahrbiicher,  Bd.  169,  1876,  p.  185;  Spiegelbero,  Lehr- 
buch,  p.  636. 


PROLAPSE  OF   THE   FUNIS,  ETC.  629 

ive  symptoms  at  the  time  of  the  accident.  The  pathognomonic  sec- 
ondary manifestations  are  outward  rotation  of  the  thighs  and  localized 
pain,  increased  by  movement  of  the  limbs  and  relieved  by  fixation  of 
the  pelvis.  Objective  evidence  of  rupture  at  the  symphysis  is  afforded 
by  the  movements  produced  at  the  articulation  by  alternate  pressure 
upon  the  ends  of  the  pubic  bones  and  by  combined  internal  and  ex- 
ternal examination.  If  the  rent  extends  to  the  vagina,  the  laceration 
may  be  detected  by  the  touch.  Separation  of  the  sacro-iliac  synchon- 
droses is  rendered  probable  if  violent  pain  is  excited  by  alternately 
pressing  the  anterior  portions  of  the  ilia  together  and  then  drawing 
them  apart  from  one  another.  Bladder  disturbances  are  rare  except  in 
cases  where  the  separation  at  the  symphysis  is  complete,  or  where  the 
rupture  is  followed  by  inflammation  and  the  formation  of  pus. 

The  treatment  consists  in  sujsporting  the  pelvis  by  means  of  a  suit- 
able bandage,  in  keeping  the  patient  upon  her  back,  and  in  maintain- 
ing strict  cleanliness.  The  bowels  should  for  a  time  be  kept  confined. 
As  regards  the  first  indication,  Spiegelberg  says  an  ordinary  towel 
properly  folded  and  fastened  at  the  pubes,  with  care  taken  to  avoid 
pressure  upon  the  crests  of  the  ilia,  will  answer  all  the  requirements. 
Eupture  of  the  pelvic  articulations,  when  not  complicated  by  other 
lesions,  or  by  puerperal  infection,  run  for  the  most  part  a  favorable 
course.  During  convalescence  the  patient  should  wear  some  form  of 
permanent  bandage,  such  as  has  been  recommended  in  cases  of  relaxa- 
tion of  the  pelvic  symphyses. 


CHAPTER   XXXIV. 

PROLAPSE  OF  THE  FUNIS,  ETC. 

Prolapsed  funis. — Asphyxia  neonatorum. — Collapse  and  sudden  death  during  labor 
and  childlied  from  thrombosis,  from  embolism,  and  from  entrance  of  air  into 
the  circulation. — On  the  extraction  of  the  child  in  case  of  death  of  the  mother 
in  pregnancy  or  labor. — Tympanites  uteri. 

Whex  the  cord  is  felt  within  the  membranes  next  to  the  present- 
ing part,  a  funis  presentation  is  said  to  exist.  After  the  membranes 
have  ruptured,  the  cord  descends  into  the  vagina,  in  front  of  the  pre- 
senting part,  and  is  then  said  to  be  prolapsed.  Generally  the  cord 
occupies  one  of  the  hollows  upon  the  sides  of  the  promontory ;  less 
frequently  it  descends  opposite  the  lateral  walls  of  the  pelvis;  the 
site  in  front  of  the  promontory  or  behind  the  pubes  is  very  excep- 
tional. 

As  regards  the  frequency  of  the  accident,  the  experience  of  individ- 
uals varies  widely.     Churchill  collected  98,512  cases  of  labor  in  which 


g30  THE  PATHOLOGY  OF  LABOR. 

it  occurred  401  times,  or  in  the  proportion  of  one  to  245*5  cases.  Dr. 
Christisen,  of  Wyandotte,  Michigan,  met  witli  it  23  times  in  1,516 
cases.  Meachem  met  with  it  10  times  in  931  cases.  Mr.  Bland  met 
with  it,  on  the  other  hand,  but  once  in  1,897  cases.* 

Prolapse  of  the  cord  occurs  only  in  cases  where  the  presenting  part 
does  not  completely  occlude  the  lower  uterine  segment.  It  is  favored 
by  a  long  cord,  by  a  deep  placental  site,  by  the  insertic  velamentosa, 
by  oblique  and  breech  presentations,  by  prolapse  of  the  extremities, 
by  hydramnios,  by  multiple  pregnancies,  and,  above  all,  by  the  con- 
tracted pelvis.  On  account  of  the  more  frequent  concurrence  of  these 
conditions  in  multiparae,  the  accident  is  oftener  found  in  them  than  in 
primparffi. 

Duncan  f  has  called  attention  to  what  he  terms  "  expression  of  the 
cord,"  i.  e.,  where  the  cord  is  squeezed  out  of  the  uterus  long  after  the 
escape  of  the  liquor  amnii.  Of  this  phenomenon  he  says  that,  during 
labor  and  after  the  discharge  of  the  waters :  "  All  parts  of  the  foetus 
are  propelled,  but  not  at  the  same  rate  .  .  . ;  and  the  rate  of  progress 
of  parts  will  vary  according  to  the  resistance.  More  mobile  parts  will 
have,  in  consequence  of  that  mobility,  less  resistance  to  encounter, 
and  it  is  plain  that  the  limbs  and  the  cord  are  the  most  mobile  of  the* 
solid  parts." 

The  diagnosis  of  prolapsed  funis  is  easy.  If  necessary,  the  loo]!  can 
be  drawn  outside  of  the  vagina.  Previous  to  rupture  it  forms  a  smooth, 
round,  compressible,  mobile  body,  not  to  be  confounded  with  any  other 
floating  object  liable  to  be  encountered  within  the  ovum.  AYhen  the 
pulsations  of  the  umbilical  vessels  are  distinctly  felt,  the  child  is  dem- 
onstrated to  be  alive.  In  the  second  stage,  however,  the  pulsations 
may  cease  for  a  moment  during  a  pain,  to  return  again  in  the  ensuing 
interval.  As  the  heart  sometimes  continues  to  beat  for  a  few  minutes 
after  the  circulation  in  the  cord  has  ended,  it  is  proper  to  carefully 
auscultate  before  assuming  death  to  have  taken  place  (Spiegelberg). 

The  prognosis,  so  far  as  regards  the  children,  is  extremely  unfavor- 
able, more  than  one  half  dying  during  labor.  This  fatality  is  owing 
to  the  pressure  to  which  the  cord  is  subjected  during  the  passage  of 
the  child  through  the  pelvis.  There  are,  however,  a  variety  of  cir- 
cumstances which  substantially  modify  the  extent  of  the  danger.  Thus, 
in  transverse  presentations  the  cord  is  scarcely  or  not  at  all  exposed 
to  pressure.  In  breech  presentations  the  prognosis  is  good,  owing  to 
the  soft  consistence  and  small  size  of  the  pelvic  extremity,  and  to  the 
fact  that,  where  the  life  of  the  child  is  in  peril,  the  conditions  are  such 
as  to  permit  of  speedy  extraction. 

*  These  statistics  I  have  borrowed  from  an  article  on  the  Presentation  of  the 
Funis,  by  Dr.  J.  G.  Meachem,  reprinted  from  The  Transactions  of  the  State  Medical 
Society  of  Wisconsin  1880. 

t  Duncan,  On  Expression  of  the  Cord,  Obstet.  Trans.,  vol.  xxi,  p.  302. 


PROLAPSE  OF  THE  FtJ:NlS,  ETC.  631 

The  most  serious  cases  are  those  where  prolapse  occurs  as  a  compli- 
cation of  head  presentations.  Engelmann  found  that  the  infant  mor- 
tality in  the  latter  was  sixty-four  per  cent,  while  in  footling  presenta- 
tions it  was  but  thirty-two  per  cent.  Favorable  conditions  in  head 
presentations  are  a  large,  roomy  pelvis  and  preservation  of  the  mem- 
branes until  cervical  dilatation  is  completed.  Of  unfavorable  import 
are  a  deep  placental  site,  a  contracted  pelvis,  and  early  rupture  of  the 
membranes. 

Treatment. — From  the  foregoing  it  will  be  seen  that  the  one  indi- 
cation for  treatment  in  this  anomaly  is  to  relieve  the  cord  from  press- 
ure. The  conduct  of  the  physician  in  each  individual  case  will  depend 
upon  the  presentation  and  the  modifying  circumstances. 

If  the  head  presents,  so  long  as  the  membranes  remain  intact,  and 
the  dilatation  of  the  cervix  is  incomplete,  an  expectant  attitude  should 
be  maintained.  Premature  rupture  should  be  guarded  against  by 
placing  the  patient  in  the  latero-prone  position,  by  forbidding  her  to 
strain,  and  by  supporting  the  membranes  by  means  of  a  moderately 
distended  Barnes  dilator  introduced  into  the  vagina.  It  is  not  ra^-e  in 
this  class  of  cases,  as  the  head  descends,  for  the  cord  to  be  withdrawn 
upward  into  a  place  of  safety.  The  more  complete  the  dilatation  be- 
fore rupture,  the  more  rapid  the  subsequent  delivery  of  the  child,  and 
the  greater  the  chance,  therefore,  of  preserving  its  life.  If,  however, 
upon  auscultation,  there  are  signs  of  failing  heart-action,  an  attempt 
should  be  made  to  push  the  cord  upward  with  the  fingers  through  the 
membranes.  In  case  of  success,  in  order  to  prevent  a  relapse,  the  sac 
should  be  ruptured,  and  the  head  should  be  brought  down  so  as  to  fill 
the  cervical  canal.  "   ' 

After  rujiture  of  the  membranes,  if  the  cervix  is  well  dilated,  the 
pains  are  good,  and  the  head  enters  quickly  into  the  pelvic  cavity,  the 
case  may  be  left  to  Nature.  Spiegelberg  mentions  five  cases,  in  his  own 
practice,  where  the  birth  of  the  child  took  place  so  rapidly  that  no 
harm  resulted  from  the  descent  of  the  cord.  If  the  pains  are  feeble, 
and  speedy  progress  is  not  made,  the  forceps  should  be  applied. 

If,  after  dilatation  of  the  cervix,  the  head  remains  high  and  mov- 
able above  the  brim,  the  forceps  should  not  be  employed.  It  is  then 
dangerous  to  the  mother,  and  offers  but  scant  hope  of  proving  of  serv- 
ice to  the  child.  The  choice  in  such  cases  falls  either  upon  reposition 
of  the  cord  or  v^ersion. 

Reposition  of  the  prolapsed  cord,  as  the  milder  procedure,  should 
be  first  attempted.  The  reposition  is  most  easily  accomplished  in  the 
knee-chest  position,  as  has  been  beautifully  demonstrated  by  Gaillard 
Thomas.* .  By  the  simple  plan  of  reversing  the  direction  of  the  uterine 
axis,  all  the  conditions  which  had  previously  favored  the  descent  of  the 

*  Thomas,  Postural  Treatment  of  Prolapsed  Funis,  Trans,  of  the  Xew  York 
Acad,  of  Med.,  1858. 


^32  THE  PATHOLOGY   OF  LABOR. 

cord  are  made  to  promote  its  return  into  the  uterine  cavity.  Thus  the 
intra-abdominal  pressure  is  removed,  tlie  amniotic  fluid  is  retained,  the 
liead  is  easily  pushed  to  one  side  so  as  to  permit  the  introduction  of 
the  hand,  and  the  cord  tends  to  glide  by  its  own  weight  over  the  de- 
clivitv  furnished  by  the  anterior  wall  to  the  fundus.  The  loop  should 
be  seized  in  the  hollow  of  the  hand,  and  should  be  carefully  sheltered 
from  pressure.  It  should  be  shoved  beyond  the  greatest  circumference 
of  the  head,  and,  where  possible,  to  the  back  of  the  child's  neck.  As 
in  all  cases  where  the  hand  has  to  be  passed  through  the  cervix,  the 
uterus  should  be  sustained  by  pressure  from  without.  AYith  the  ad- 
vent of  a  pain,  all  manipulation  should  cease,  to  be  renewed,  however, 
as  relaxation  follows.  If  the  replacement  proves  successful,  the  hand 
should  be  withdrawn  gradually,  while  the  head  becomes  fixed  in  the 
lower  segment.  This  latter  result  may  frequently  be  expedited  by 
judiciously  directed  external  pressure.  As  a  precaution  against  relapse, 
the  patient  should  be  placed  in  the  latero-prone  position,  with  the  hips 
elevated  by  a  pillow. 

The  Postural  Trentment  of  Prolapse  of  the  Funis.— K.  F.  .T.  Birubaum*  finds 
that  quite  frequent  mention  has  been  made  by  authors  of  the  advantages  to  be 
derived  from  posture  in  the  treatment  of  cases  of  prohipsed  funis.  Tlie  works 
of  Camper,  published  about  the  middle  of  the  seventeenth  century,  and  referred 
to  by  Kiestra,  he  had  no  means  of  obtaining  access  to.  Deventer  t  considers  the 
subject  of  prolapsed  funis  in  extenso,  takes  up  its  different  modifications,  its 
effect  upon  parturition  and  the  life  of  the  child,  and  the  treatment  it  demands. 
In  cases  where  the  cord  was  pressed  against  either  ilium,  he  directed  to  place 
the  woman  upon  the  corresponding  side,  with  raised  pelvis,  and  with  the  hand 
(right  hand  if  on  the  left  side,  and  vice  versa)  to  lift  the  head,  replace  the  cord, 
then,  as  seemed  advisable,  either  to  bring  the  head  into  the  pelvis,  or  to  turn 
and  extract  by  the  feet.  When  the  cord  was  pressed  against  the  pubes  or  the 
sacrum,  he  advised  that  the  midwife  should  place  the  woman  upon  her  knees 
with  her  body  thrown  forward,  and  that,  in  this  position,  the  accoucheur  should 
raise  the  head  and  return  the  cord ;  if  the  woman  should  be  too  weak  for  this, 
she  should  be  placed  upon  the  side  with  one  limb  drawn  up  under  the  body. 
John  Mowbray  |  advises  that  the  woman,  if  strong  enough,  should  be  placed 
upon  her  knees  and  elbows  in  cases  where  the  cord  lies  next  the  sacrum  or  the 
pubes.  Henry  Bracken,  a  pupil  of  Boerhaave,*  proposed  returning  the  funis 
in  head  presentations,  with  the  woman  placed  upon  the  knees,  and  afterward  to 
bring  the  fetal  head  into  the  pelvis.  Ludwig  Wilhelm  von  Knoer  ||  devoted  a 
long  chapter  to  funis  presentations.  He  says:  "Introduce  the  hand  so  soon  as 
the  membranes  rupture,  and,  according  to  the  position  of  the  child,  perform 
either  podalic  or  cephalic  version,  placing  the  woman  at  the  same  time  upon 

*  Monatsschr.  f.  Geburtsk.,  October,  1867. 

t  Operationes  ehirurgic;«  novum  lumen  exhibentes  obstetricantibus,  Lugd.  Bat., 
1701. 

t  The  Female  Physician,  containing  all  the  Diseases  incident  to  that  Sex,  Lon- 
don. 1724. 

*  Midwife's  Companion ;  or  a  Treatise  of  Midwifery,  London,  1737. 
II  Frauen-Zimmer  Medicus,  Leipsic,  1747. 


PROLAPSE  OF  THE  FUNIS,  ETC.  633 

her  knees  to  prevent  the  protrusion  of  the  cord."  George  Daniel  Boessel*  rec- 
ommends turning  in  cases  of  funis  presentation,  and,  in  cases  of  difficulty,  to 
perform  version  with  the  woman  placed  ujion  the  knees.  In  recent  times.  Van 
Kitgen  has  certainly  been  the  most  ardent  partisan  of  postural  methods  of  treat- 
ment. In  his  work  entitled  Anzeigen  der  mechanischen  Hulfen  bei  Entbin- 
dungen,  published  in  1830,  he  recommends  them  in  a  great  variety  of  circum- 
stances, but  not  then  for  prolapsed  funis ;  but  in  his  Lehr-  und  Handbuch  der 
Geburtshiilfe  fiir  Hebammen  (Mainz,  1838)  he  says:  "When  the  funis  presents, 
the  midwife  should  instantly  send  for  the  accoucheur;  meanwhile  she  should 
herself  place  the  woman,  if  strong  enough,  upon  her  knees  and  elbows,  and 
attempt  the  replacement  of  the  cord ;  if  the  woman  is  too  weak  to  admit  of 
this,  she  should  be  placed  upon  her  side,  with  elevated  pelvis.  That  side 
should  be  chosen  upon  which  the  funis  is  not  situated.  If  the  manipulation  is 
successful,  the  posture  should  be  maintained  to  prevent  a  recurrence  of  the  jjro- 
lapse."  He  recommends  the  position  upon  the  elbows  and  knees  for  cases  of 
prolapsed  funis  and  transverse  presentations  in  breech  or  foot  presentations,  also 
where  the  head  is  movable  above  the  brim,  and  where  there  is  no  attainable 
presenting  part.  He  advises  returning  the  funis  high  up  with  the  hand,  and 
then  to  let  it  fall  into  the  uterus,  where  it  would  no  longer  be  subjected  to 
pressure.  After  reposition,  place  the  woman  upon  her  side,  with  raised  pelvis. 
Sometimes  the  postural  method  suffices  without  any  manipulations.  Kiestra  f 
advises  the  position  upon  the  knees  and  elbows  in  cases  where  the  cord  is  felt 
near  the  head  previous  to  rupture  of  the  membranes,  to  prevent  the  occurrence 
of  prolapse.  After  the  rupture  of  the  membranes,  he  says,  the  same  position 
should  be  employed  to  facilitate  the  return  of  the  cord,  and  should  be  main- 
tained until  the  head  is  fairly  engaged  in  the  pelvis.  Where  the  position  could 
not  be  endured  long  enough,  he  counseled  placing  the  woman  in  a  half-kneel- 
ing, half-recumbent  posture,  with  the  sides  supported  by  cushions.  Theobold, 
in  1860,  hit  upon  the  same  idea.  He  considered  the  most  favorable  condition 
for  the  return  of  the  funis  was  to  place  the  woman  upon  her  head,  but,  in  view 
of  the  difficulty  attending  the  execution  of  this  manojuvre,  compromised  the 
matter  by  suggesting  the  position  upon  the  elbows  and  knees. 

The  advantages  of  the  postural  method  in  the  treatment  of  pro- 
lapsed cord  are  beyond  all  question.  It  is,  however,  difficult  to  per- 
suade the  woman  to  long  maintain  so  constrained  an  attitude,  and  the 
cases  are  not  rare  where,  in  spite  of  gravity,  the  cord  is  exjjressed  from 
the  uterine  cavity.  Efforts  at  replacement  should  not,  therefore,  be 
long  continued.  It  is  impossible  to  handle  the  cord  for  any  lengthy 
period  without  enfeebling  the  force  of  the  fetal  heart.  So  soon,  there- 
fore, as  it  becomes  evident  that  nothing  is  to  be  gained  by  further  per- 
sistence, the  hand  should  be  pushed  up  to  the  feet,  and  the  safety  of 
the  child  should  be  secured  by  speedy  extraction.  In  cases  of  con- 
tracted pelvis  the  question  of  version  must  be  decided  with  reference 
to  the  interests  of  the  mother,  as  a  difficult  breech  delivery  complicated 
by  prolapsed  funis  offers  but  a  sorry  prospect  of  saving  the  life  of  the 
child. 

*  Grundlegung  zur  Ilebamnien-Kunst,  Flensburg  and  Leipsic,  1756. 

t  Ncderl.  Weekbl.,  April,  1855. 


634 


THE  PATHOLOGY  OF  LABOR. 


If  the  membranes  rupture  and  the  cord  is  prolapsed  while  the  cer- 
vix is  still  narrow  and  rigid,  an  attempt  should  first  be  made  to  push 
back  the  cord  with  two  fingers  after  placing  the  woman  in  the  genu- 
pectoral  position.  As  a  rule,  however,  instrumental  replacement  will 
be  necessary.  I  have  been  in  the  habit  of  employing  for  the  purpose, 
as  recommended  by  Dudan,  a  large  English  catheter,  which  possesses 
the  advantage  of  forming  one  of  the  ordinary  properties  of  the  phy- 
sician. The  method  of  using  the  instrument  is  as  follows :  A  piece  of 
tape  should  first  be  fastened  loosely  around  the  cord,  the  stylet  should 
then  be  made  to  emerge  at  the  e3'e  of  the  catheter,  and  a  loop  of  the 
tape  should  be  placed  in  the  angle  it  forms.  By  returning  the  stylet 
and  pushing  it  forward  to  the  extremity  of  the  tube,  the  band  is  held 
firmly.  After  replacing  the  prolapsed  cord,  the  catheter  is  readily  de- 
tached by  the  witlidrawal  of  the  stylet.  Brauu  von  Fernwald,  who  is 
the  author  of  tlie  best  of  the  repositors  made  expressly  for  the  pro- 
lapsed cord,  says  that  the  catheter  is  almost  the  only  instrument  to 
which  he  now  resorts. 

Instrumental  replacement  is  apt  to  prove  a  veritable  labor  of  Sisy- 
phus.    As  one  loop  is  pushed  up  another  comes  down,  or  the  entire 

mass  is  returned  with  infinite  trouble 
to  the  uterus  only  at  once  to  be  i^ro- 
jected  into  the  vagina.  Roberton 
has  proposed  a  handy  plan  for  such 
Cases,  which  certainly  merits  a  trial. 
It  consists  in  first  passing  a  piece 
of  twine  doubled  through  an  elastic 
catlieter,  so  that  the  loop  makes  its 
appearance  at  the  eye.  Through 
tliis  loop,  a  loop  of  the  cord  should 
be  drawn.  The  ends  of  the  twine 
should  then  be  knotted  to  prevent 
them  from  slipping;  the  catheter 
should  be  armed  with  a  stylet,  and 
should  be  pushed  upward  into  the 
uterus,  carrying  the  cord  with  it. 
After  introducing  the  catheter,  the  stylet  should  be  withdrawn,  and 
the  instrument  should  be  left  behind  to  keep  the  cord  from  again 
prolapsing. 

In  one  case  Dr.  Ashford*  succeeded  in  attaching  the  cord  to  a 
Gariel  pessary.  The  latter  was  then  carried  into  the  uterus,  and  in- 
flated to  prevent  its  expulsion. 

If  neither  the  cord  can  be  returned  nor  the  child  extracted,  it  is 
proper  to  try  by  Braxton  Hicks's  method  to  convert  the  head  presenta- 

*  F.  A.  Ashford,  '  Ballooning'  the  Prolapsed  Umbilical  Cord,  Am.  Jour,  of  Ob- 
stet.,  October  1878,  p.  745. 


Fig.  331.— Roberton's  repositor. 


PROLAPSE  OP  THE  FUNIS,  ETC.  635 

tion  into  one  of  tlie  shoulder  or,  better  still,  of  the  breech,  in  order  by 
so  doing  to  relieve  the  umbilical  vessels  from  pressure.  Of  course,  if 
the  prolapsed  funis  is  associated  with  pelvic  contraction,  the  rule  here- 
tofore given  to  consult  first  the  safety  of  the  mother  remains  the  guid- 
ing one  in  practice. 

In  face  presentations  version  is  indicated,  as,  owing  to  the  imper- 
fect manner  in  which  the  face  closes  the  uterine  orifice,  replacement  of 
the  cord  is  not  likely  to  prove  successful.  If  the  opening  through 
which  the  cord  makes  its  way  into  the  vagina  is  produced  by  a  pro- 
lapsed extremity,  the  latter,  of  course,  should  be  pushed  back  after  the 
cord  has  been  returned.  In  footling  cases  the  pressure  on  the  cord 
does  not  begin  until  long  after  the  extremities  can  be  reached  and 
utilized  for  extraction.  In  full  breech  cases,  where  the  size  of  the  pre- 
senting part  might  interfere  with  the  funic  circulation,  where  it  is  pos- 
sible to  return  the  cord  with  the  hand  it  is  equally  practicable  to  bring 
down  an  extremity.  In  cross-births,  before  the  shoulder  becomes 
wedged  in  the  pelvis  the  cord  is  in  no  danger.  No  treatment  is  there- 
fore necessary,  except  that  indicated  by  the  faulty  presentation. 

Suspended  Animation  or  Asphyxia  Neonatorum. 

Definition. — The  term  suspended  animation  is  applied  to  such 
grades  of  congenital  asphyxia  in  the  living  new-born  child  as  are  not 
incompatible  with  the  continuance  of  its  life.  A  larger  number  of 
males  than  of  females  are  borne  asphyxiated,  and  the  children  of  primi- 
parae  are  more  liable  to  this  condition  than  those  of  multipara. 

Etiology. — A  perfect  comprehension  of  the  etiology  of  suspended 
animation  must  be  based  upon  thorough  knowledge  of  the  physiology 
of  intra-uterine  life  and  of  the  conditions  necessary  to  its  preservation. 

During  the  period  of  gestation  the  child  remains  in  a  state  of  apnoea, 
and  the  respiratory  function  necessary  to  its  development  is  performed 
by  the  placenta.  So  soon,  however,  as  the  child  is  born,  in  normal 
cases,  the  thorax  expands,  the  diaphragm  contracts,  and  pulmonary  res- 
piration is  established.  The  premature  establishment  of  pulmonary 
respiration  while  the  child  is  still  in  the  utero-genital  passage,  owing  to 
the  absence  of  an  atmospheric  medium,  is  followed  by  asphyxia,  and  is 
the  usual  cause  of  still-births. 

The  reason  of  the  first  respiratory  movement  in  the  child,  whether 
prior  or  subsequent  to  its  "birth,  has  long  been  a  subject  for  speculation. 
Omitting  earlier  views,  at  present  two  theories  contend  for  supremacy. 
The  one  formulated  by  Schwartz  maintains  that  in  all  cases  the  respira- 
tory act  is  due  to  disturbed  placental  circulation,  and  the  consequent 
lack  of  oxygen  in  the  blood  of  the  child.  Preyer,  on  the  other  hand,  in- 
sists that  respiration  is  a  reflex  movement  provoked  by  cutaneous  stim- 
uli.    He  admits,  however,  that  a  venous  condition  of  the  blood  favors 


4    : 


g36  THE  PATHOLOGY  OF  LABOR. 

the  action  of  external  stimuli  by  increasing  the  irritability  of  the  respira- 
tory centres. 

As  a  contribution  to  the  solution  of  the  questions  in  dispute,  Otto 
Eno-strom*  has  recently  reported  a  series  of  experiments  made  by  him 
upon  gravid  rabbits  and  guinea-pigs,  in  Preyer's  laboratory.  The  ani- 
mals were  strapped  to  a  board,  and  were  then  immersed  in  a  saline  solu- 
tion (six  per  cent),  which  was  kept  at  blood-heat  by  a  special  apparatus. 
The  head  of  the  animal  was  placed  above  the  fluid.  A  small  incision 
was  then  made  in  tlie  abdominal  wall,  through  which  a  uterine  coruu 
was  allowed  to  escape  into  the  saline  fluid.  The  uterine  walls  were 
next  opened  opposite  the  mesenteric  attachment  at  the  point  of  least 
vascularity.  As  there  was  no  haemorrhage  to  stain  the  saline  fluid,  it 
was  possible  to  observe  the  foetuses  through  the  membranes  in  the  clear 
amniotic  fluid.  When  this  experiment  was  performed  with  address 
and  dexterity,  the  exposed  foetus  remained  in  a  state  of  apnoea,  and  the 
blood  in  the  umbilical  vein  possessed  a  bright-red  color,  in  marked  con- 
trast with  dark  hue  of  the  blood  in  the  umbilical  arteries. 

If  now  the  cord  was  compressed  through  the  membranes  by  the 
thumb  and  index-finger  of  the  warmed  hand,  or  by  self-closing  compress- 
ing forceps  applied  to  the  cord  near  to  the  placenta,  and  as  far  from 
the  foetus  as  possible,  respiration  followed  in  from  three  to  six  seconds, 
and  continued  until  death  supervened  from  asphyxia.  The  same  results 
followed  when  the  umbilical  vein  was  pricked  with  a  needle,  or  was 
divided  by  scissors.  Again,  in  other  cases,  to  avoid  the  criticism  that 
external  stimuli  were  not  absolutely  excluded  by  the  manipulations  em- 
ployed, the  mother  was  asphyxiated  by  carbonic-acid  gas,  or  poisoned  by 
woorari,  or  bled  to  death  by  opening  the  carotid.  Here,  too,  soon  after 
the  blood  in  the  umbilical  vein  became  of  a  venous  hue,  respirations 
occurred  as  heretofore,  though  all  manipulations  were  carefully  avoided. 
It  is,  therefore,  demonstrated  that  fetal  respirations  are  excited,  in  the 
absence  of  external  sources  of  irritation,  so  soon  as  the  blood  in  the 
umbilical  veins  becomes  darkened,  or  is  cut  off  from  the  foetus. 

On  the  other  hand,  in  another  series  of  cases,  where  the  amniotic  sac 
was  exposed  under  a  blood-warm  saline  fluid,  and  the  apnoea  was  not 
disturbed,  Engstrom  gently  pricked  the  extremities  of  the  foetus  with  a 
needle.  Reflex  movements  were  excited,  but  the  apnoea  continued. 
When,  however,  deep  puncture  was  made,  the  alae  nasi  dilated,  the 
mouth  opened,  and  thoracic  inspiration  was  evoked.  The  effect  was, 
however,  momentary,  and  the  apncea  returned. 

Again,  in  order  to  reduce  the  disturbance  of  the  placental  circulation 
to  a  minimum,  Engstrom,  following  a  method  invented  by  Preyer, 
seized  the  head  of  a  foetus  with  the  thumb  and  index-finger  through  the 
abdominal  walls,  and  then  cut  through  the  abdominal  coverings,  the 
uterine  walls,  and  amniotic  sac  to  the  nose  of  the  animal.  The  nose 
*  Ueber  die  Ursachen  der  Ersten  Athembewegungen. 


PROLAPSE  OF  THE  FUNIS,  ETC.  637 

was  then  lifted  above  the  saline  fluid  and  exposed  to  the  atmosphere. 
By  means  of  powerful  currents  of  induced  galvanism  applied  to  the 
nasal  organ,  respiratory  movements  were  excited,  but  ceased  when  the 
current  was  removed.  It  seemed  doubtful,  however,  whether  inspiratory 
acts  did  occur  in  either  series  of  experiments  so  long  as  the  placental 
circulation  was  completely  undisturbed.  The  existence  of  apnoea  in  the 
foetus  is  not  conclusive  evidence  that  the  opening  of  the  uterus  or  the 
compression  of  the  uterine  walls  produces  no  derangement  in  the  blood- 
currents  of  the  placenta.  The  results  were  often  negative  at  the  begin- 
ning of  the  experiment,  but,  as  the  blood  in  the  umbilical  vein  darkened, 
the  electric  and  mechanical  irritants  produced  more  and  more  marked 
effects. 

From  these  experiments  it  becomes  evident  that  when  the  placental 
respiration  is  suspended,  the  accumulation  of  unknown  materials  in  the 
blood  is  capable  of  exciting  the  respiratory  center  in  the  medulla 
oblongata  of  the  foetus  without  the  aid  of  peripheral  stimuli ;  but  that 
the  latter  are  capable  of  exciting  the  respiratory  act  before  the  internal 
stimuli  have  increased  sufficiently  to  induce  independent  action.  Again, 
it  is  a  familiar  fact  that  in  moderate  degrees  of  asphyxia  in  the  new-born, 
after  the  irritability  of  the  medulla  has  been  lowered  to  a  point  at 
which  no  response  follows  from  the  venous  condition  of  the  blood,  ex- 
ternal stimuli  are  still  capable  of  exciting  respiratory  movements. 

Engstrom  found,  too,  that  when  the  foetus  had  breathed  in  the 
amniotic  sac,  after  respirations  had  ceased,  and  after  the  blood  in  the 
umbilical  vein  and  arteries  had  become  of  the  same  blue  color,  and  the 
nose  and  lips  had  become  cyanotic,  it  was  still  possible  to  excite  res- 
pirations in  some  cases  by  opening  the  amnion  and  lifting  the  head  so 
as  to  expose  it  to  the  air,  and  in  others  by  pinching  the  nostrils,  the 
ears,  and  the  mouth.  For  the  sake  of  convenience,  I  shall  take  the 
liberty  of  recalling  at  this  point  the  peculiarities  of  the  fetal  circula- 
tion. The  arterialized  blood  in  the  umbilical  vein  empties  partly  into 
the  portal  vein,  and  is  first  distributed  to  the  liver,  and  in  part  passes 
by  the  ductus  venosus  into  the  inferior  vena  cava.  The  mingled  venous 
and  arterial  currents  then  enter  the  right  auricle,  and  are  in  early 
pregnancy  directed  by  the  Eustachian  valve  across  the  right  auricle  to 
the  left  auricle,  and  thence  pass  to  the  left  ventricle.  As  the  heart 
contracts,  the  blood  is  driven  from  the  left  ventricle  to  the  aorta,  and 
is  thence  distributed  by  the  large  vessels  which  spring  from  the  latter 
to  the  head  and  upper  extremities.  The  blood  returned  from  the  upi)er 
portion  of  the  body  by  the  superior  vena  cava  enters  the  right  auricle, 
where  it  passes  in  front  of  the  Eustachian  valve  to  the  right  ventricle. 
With  the  advance  of  gestation,  however,  a  gradual  disappearance  of  the 
Eustachian  valve  takes  place,  so  that  a  part  of  the  blood  from  the  in- 
ferior cava  enters  with  that  of  the  superior  cava  into  the  right  ventricle. 
The  contraction  of  the  right  ventricle  forces  the  blood  into  the  pul- 


g38  THE  PATHOLOGY  OF  LABOR. 

monary  artery,  which  distributes  an  insignificant  quantity  to  the  hmgs, 
while  the  main  current  passes  through  the  ductus  arteriosus  to  the 
aorta,  by  which  it  is  distributed  to  the  lower  portion  of  the  body.  Now, 
though  the  greater  part  of  the  regenerated  placental  blood  is  distributed 
to  the  head  and  upper  part  of  the  body,  it  is  mingled  largely  with 
venous  blood  returning  from  other  organs,  and  that  which  goes  to  the 
respiratory  center  in  the  medulla  oblongata  is  of  a  character  which 
would  cause  dyspnroic  manifestations  in  self-breathing  individuals. 

During  labor,  especially  in  the  last  stage,  the  placental  aeration  of 
the  blood  is  interfered  with  by  the  uterine  contractions,  and  in  its 
passage  through  the  pelvis  the  surface  of  the  child  is  subjected  to 
pressure  and  friction.  At  birth  the  body  is  exposed  to  the  air.  These 
combined  causes  as  a  rule  are  followed  by  pulmonary  respiration, 
though  in  some  instances  of  lowered  irritability  of  the  medulla  pro- 
longed apnoea  follows  the  birth  unless  the  child  is  made  to  cry  by 
vigorous  slapping. 

As  the  chest  expands  in  the  act  of  inspiration  the  lungs  fill  with  air, 
and  the  blood  from  the  pulmonary  artery  pours  into  the  opened  pulmo- 
nary vessels.  The  pressure  in  all  the  vessels  of  the  body  is  diminished, 
though  in  the  thorax  a  partial  compensation  takes  place  from  the  aspi- 
ration of  blood  from  the  veins  which  enter  the  intrathoracic  sjDace. 
The  diminution  of  .pressure  is  greatest  in  the  pulmonary  artery.  The 
current  which  empties  into  the  aorta  becomes  of  feeble  force,  and  final- 
ly ceases  altogether.  The  ductus  arteriosus  gradually  closes,  and  the 
pulmonary  circuit  becomes  complete.  The  withdrawal  of  the  blood  from 
the  pulmonary  artery  and  the  force  of  aspiration  lower  the  tension  in 
the  aorta.  The  heart  beats  more  slowly.  The  resulting  diminished 
arterial  pressure  is  most  felt  in  the  extremities.  The  pulsation  of  the 
umbilical  arteries  as  a  consequence  ceases,  and  the  placental  circulation 
is  suspended. 

In  the  asphyxia  of  new-born  infants  the  suspended  animation  is,  with 
few  exceptions,  preceded  by  intra-uterine  respirations.  The  causes  of 
the  latter  are  to  be  found  in  tetanic  contractions  of  the  uterus  and  the 
consequent  diminished  blood-supply  to  the  placenta,  in  premature 
detachment  of  the  placenta,  in  compression  of  the  cord,  in  acute  anae- 
mia, and  in  the  sudden  death  of  the  mother.  Of  these,  the  compres- 
sion of  the  cord  is  by  far  the  most  common. 

The  first  effect  of  the  compression  of  the  cord  is  to  arrest  the  cir- 
culation in  the  umbilical  arteries.  The  pressure  in  the  aorta  is  thereby 
augmented,  and  increased  work  is  thrown  upon  the  left  ventricle  of  the 
heart.  Except  in  cases  where  the  mouth  and  nasal  passages  are  closed 
by  pressure,  with  the  expansion  of  the  chest,  due  to  the  irritation  of  the 
medulla  by  the  increased  venosity  of  the  blood,  amniotic  fluid,  meco- 
nium, and  mucus  are  aspirated  into  the  air-passages.  When  the  com- 
pression of  the  cord  is  temporary  the  circulation  may  be  restored,  and 


PROLAPSE   OF   THE   FUNIS,   ETC.  639 

the  apnoea  may  again  return ;  but  in  cases  where  the  respirations  con- 
tinue, the  capilhiries  of  the  kings  fill  with  blood  from  the  pulmonary 
artery,  the  intrathoracic  venous  congestion  is  increased,  and  the  heart 
action  is  lowered.  As  the  irritability  of  the  medulla  sinks,  the  res- 
pirations fail,  the  cavities  of  the  heart  fill  with  venous  blood,  the  lungs 
are  congested,  and  in  some  instances  subpulmonary  ecchymoses  result 
from  overdistention  of  the  pulmonary  vessels.  Outside  the  thoracic 
cavity,  the  venous  trunks  are  often  distended  with  blood.  This  second- 
ary venous  stasis  is  most  marked  in  the  vessels  of  the  neck,  head,  and 
brain,  but  to  a  less  degree  venous  stases  are  likewise  observed  in  the 
abdominal  organs  and  in  the  capillaries  of  the  skin. 

Suspended  animation  may  exceptionally  occur  without  antecedent 
intra-uterine  respiration.  This  is  the  case  when  disturbance  or  arrest 
of  the  placental  functions  takes  place  in  foetuses  so  immature  that 
their  medullary  centers  can  not  respond  to  the  irritation  of  insufficiently 
oxygenated  disassimilative  products  by  originating  the  nervous  impulse 
necessary  for  the  production  of  respiratory  movements.  Another  cause 
of  suspended  animation  unattended  by  intra-uterine  respiration  is,  ac- 
cording to  Schultze,  a  very  slow  progress  of  the  placental  respiratory  dis- 
turbance, and  a  consequent  gradual  diminution  of  the  amount  of  oxy- 
gen in  the  fetal  blood.  The  deficiency  in  oxygen  is  at  first  so  slight 
as  not  to  stimulate  the  medullary  center,  and  when  the  deficiency  be- 
comes more  marked,  the  irritability  of  the  medulla  has  been  so  much 
depressed  that  it  is  no  longer  capable  of  originating  a  respiratory  im- 
pulse. In  this  case  the  foetus  dies  or  passes  into  a  condition  of  sus- 
pended animation  without  having  breathed  at  all.*  Compression  of 
the  fetal  brain  due  to  a  contracted  pelvis,  to  intracranial  haemorrhage, 
to  the  use  of  the  forceps,  f  or  to  delivery  in  breech  positions,  may  occa- 
sion death  or  suspended  animation  without  exciting  respiratory  move- 
ments. The  rationale  of  such  cases  is  as  follows :  Cerebral  compres- 
sion reduces  or  even  arrests  the  heart's  action  by  irritating  the  pneu- 
mogastric  nerve.  The  placental  respiratory  function  is  thus  impaired, 
the  fetal  blood  is  consequently  deprived  of  oxygen,  and  the  irritability 
of  the  medulla  so  reduced  that  the  latter  can  no  longer  originate  re- 
spiratory movements.  J  If  intracranial  extravasations  are  located  upon, 
the  convexity  of  the  cerebrum,  they  are  comparatively  innocuous,  since 
the  medulla  is  not  compressed.  Their  most  pernicious  effect  is  natu- 
rally observed  when  they  are  situated  at  the  base  of  the  brain. 

Morbid  Anatomy. — Schultze  recognizes  two  stages  of  suspended 
animation,  which  correspond  to  the  terms  asphyxia  livida  and  pallida, 
usually   employed    to    designate    these   respective    conditions.**      The 

*  Schultze,  op,  cit.,  pp.  103  et  seq. 

+  DoHRN,  Arch.  f.  Gynaek.,  Bd.  vi.  1874.  p.  365. 

X  Frankenhauser,  Monatsschr.  f.  Geburtsk.,  Bd.  xv,  1860,  p.  368. 

*  Schultze,  op.  cit.,  pp.  6,  130,  147. 


u 


g^Q  THE  PATHOLOGY  OF  LABOR. 

boundary  line  between  the  two  stages  is  marked  by  the  loss,  on  the 
part  of  the  muscles,  of  their  tonic  contractility.  In  the  first  stage  the 
muscular  tone  is  still  jn-eserved. '  Although  there  are  no  spontaneous 
muscular  contractions,  the  extremities  are  not  completely  relaxed,  nor 
does  the  head  drop.  Reflex  movements  are  easily  produced  by  surface 
irritation.  The  skin  is  dusky  red  or  cyanotic,  the  cutaneous  vessels  are 
turgid,  the  conjunctivae  injected,  and  the  eyeballs  protruding.  The 
cardiac  and  umbilical  pulsations  are  slow  but  forcible.  The  umbilical 
vessels  are  fully  distended.  Respiratory  movements  usually  occur  only 
after  a  certain  interval.  They  are  at  first  feeble,  superficial,  and  at- 
tended by  facial  contortions,  but  soon  become  more  powerful.  The 
increased  deficiency  in  oxygen,  occasioned  by  delivery,  often  furnishes 
to  the  medulla,  in  this  stage  of  suspended  animation,  a  stimulus  of 
sufficient  intensity  to  cause  spontaneous  respiratory  movements.  The 
same  result  is  attained  by  irritation  of  the  surface.  If  respiration  does 
not  ensue  from  either  cause,  the  child  passes  into  the  second  stage  of 
asphyxia. 

In  the  second  stage  of  suspended  animation,  or  asphyxia  pallida, 
the  children  are  exceedingly  anaemic.  The  conjuctivse  are  without 
luster;  the  surface  is  col^;  the  sphincters  are  relaxed;  the  limbs, 
head,  and  lower  jaw  hang  loosely  down.  Reflex^moyements  do  not 
occur.  The  cardiac  beats  are  frequent  and, feeble.  The  umbilical 
pulse  is  almost  or  quite  imperceptible.  The  umbilical  vessels  are 
empty.  Either  no  spontaneous  respiratory  movements  occur  or  they 
are  few,  snapping,  and  produced  by  the  diaphragm,  without  the  par- 
ticipation of  the  facial,  nasal,  or  maxillary  muscles.  The  respirations 
are  ineffectual,  since  a  post-mortem  examination  reveals  little  or  no  air 
in  the  bronchi,  which  are  usually  filled  witli  fluid  matter,  and  since 
no  rales  are  heard  during  the  respiratory  efforts.  The  medulla  is  so 
completely  paralyzed  that  the  stimulus  of  the  increased  deficiency  in 
oxygen,  attendant  upon  delivery,  merely  produces  these  futile  respira- 
tory efforts.  Should  artificial  means  succeed  in  restoring  the  child, 
the  first  signs  of  its  resuscitation  will  be  refilling  of  the  cutaneous 
capillaries  and  returning  muscular  tonicity.  The  morbid  anatomical 
features  of  suspended  animation  vary  according  as  that  condition  has 
or  has  not  been  attended  by  intra-uterine  respiration.  In  the  latter 
case  the  blood  is  dark  and  uncoagulated.  The  pulmonary  vessels  are 
widely  distended.  The  lungs  are  enlarged,  heavy,  and  of  a  dark-red 
color.  Numerous  pulmonary,  subpleural  subpericardial,  and  suben- 
docardial ecchymoses  are  present.  The  pulmonary  extravasations  are 
more  extensive  than  in  cases  of  asphyxia  accompanied  by  intra-uterine 
respiration,  for  the  reason  that,  in  the  latter,  the  aspirated  fluids  offer 
a  certain  support  to  the  distended  capillaries.  Pulmonary  congestion 
and  ecchymosis  may  be  absent  if  the  inspirations  were  ineffectual,  in- 
frequent, and  of  short  duration.     The  obstruction  of  the  pulmonary 


PROLAPSE   OF  THE  FUNIS,  ETC.  641 

circulation  further  produces  venous  congestion  of  the  surface,  of  the 
abdominal  organs,  and  of  the  encephalon  resulting  in  subconjunctival, 
meningeal,  and  cerebral  hemorrhages.  Ecchymoses  may  also  be 
found  beneath  and  upon  the  pericranium.  Aside  from  the  extrava- 
sated  blood,  no  foreign  matters  are  found  in  the  bronchi.  The  absolute 
proof  that  the  asphyxia  of  still-born  children,  or  of  those  born  in  a 
moribund  condition,  was  attended  by  iutra-uterine  respiration  consists 
in  the  discovery,  within  the  bronchi,  of  substances  introduced  by  tho- 
racic aspiration.  When  the  proof  is  lacking,  inspiration  may  still 
have  occurred,  but  the  entrance  of  foreign  bodies  has  been  prevented 
through  occlusion  of  the  nose  and  mouth  by  portions  of  the  membranes, 
or  by  close  appositian  to  them  of  the  maternal  soft  parts.  The  quan- 
tity of  aspirated  material  will  depend  upon  its  character  and  the  force 
of  the  inspirations.  The  tough  cervical  mucus  penetrates  only  to  the 
trachea  and  primary  bronchi.  The  liquor  amnii,  containing  meconium, 
vernix  caseosa,  and  blood  and  downy  hairs,  may  even  reach  the  ter- 
minal bronchioles.  If  air  had  found  an  entrance  into  the  uterine 
cavity,  it  is  also  present  in  the  bronchi,  and,  exceptionally,  in  the 
stomach  and  duodenum.  The  dilatation  of  the  Eustachian  tubes,  as 
a  consequence  of  the  first  inspirations,  permits,  in  some  instances,  ac- 
cording to  Wendt,  *  the  penetration  of  liquor  amnii  into  the  middle 
ear.  The  pulmonary  ecchymoses  are  less  numerous  and  extensive  in 
asphyxia  attended  by  intra-uterine  respiration  than  in  the  other  va- 
riety, for  reasons  above  stated,  but  congestion  and  extravasations  in 
the  abdominal  and  cerebral  organs  are  quite  as  constant  and  important. 
Diagnosis. — An  important  diagnostic  symptom  of  beginning  as- 
phyxia is  diminished  frequency  of  the  fetal  heart-beats,  due  to  inhibi- 
tion of  the  placental  respiration..  This  has  no  significance  if  it  be 
manifest  only  during  the  pains,  since  it  is  then  a  physiological  occur- 
rence due  to  the  mechanical  compression  of  the  foetus  or  to  expression 
of  the  placental  blood  into  the  fetal  vessels.  If  it  persist,  however, 
during  the  interval  between  the  pains,  and  be  jirogressive,  it  is  of  seri- 
ous import,  betokening  either  considerable  compression  or  irritation  of 
the  medulla  by  an  excess  of  deoxygeuated  blood.  The  diminished 
frequency  is  sometimes  succeeded  by  increased  rapidity  of  the  cardiac 
contractions,  indicating  p.arah'sis^  of  the  pneumogastric,  and,  conse- 
quently, a  more  advanced  stage  of  suspended  animation,  f  This  in- 
creased rapidity  is,  probably,  invariably  preceded  by  the  diminished 
frequency  of  the  heart's  action  already  alluded  to.  The  evacuation  of 
meconium  is  also  diagnostic  of  asphyxia,  provided  it  be  not  merely  the 
result  of  the  mechanical  compression  exerted  upon  the  child  in  breech 
presentations.  The  appearance  of  the  meconium  is,  probably,  due  to 
the  increased  intestinal  peristalsis  attendant  upon  asphyxia,  although, 

*  Spiegelberg,  Lehrbueh.  p.  667. 

f  HuTER,  itloiiatsschr.  f.  Geburtsk.,  Bd.  xviii,  1862,  Supplem.  Heft,  p.  48. 
41 


g^2  THE  PATHOLOGY  OF  LABOR. 

perhaps,  in  part  occasioned  by  relaxation  of  the  sphincters  and  com- 
pression of  the  abdomen  by  the  contracting  diaphragm.  The  dis- 
charge of  meconium,  accordingly,  usually  attends  that  form  of  sus- 
pended animation  in  which  intra-uterine  respiration  has  occurred,  and 
is  absent  in  those  cases  of  gradually  induced  asphyxia  unaccompanied 
by  respiratory  efforts.  The  differential  diagnosis  between  these  two 
varieties  is  completed,  after  delivery,  by  the  detection  of  bronchial 
rales,  due  to  the  aspiration  of  intra-uterine  fluids,  in  all  cases  of  intra- 
uterine respiration  except  those  in  which  the  external  air-passages 
were  occluded.  The  discharge  of  meconium  is  sometimes  not  in- 
dicative of  any  pathological  condition.  Schultze  *  detected  intra-uter- 
ine respiration  by  abdominal  auscultation,  as  well  as  by  intra-uterine 
palpation,  and  numerous  observers  have  heard  the  vagitns  uteriims,  or 
intra-uterine  cry,  which  bears  testimony  to  the  entrance  of  air  into  the 
uterus,  and  to  the  occurrence  of  respiratory  movements,  f  When  de- 
livery has  been  partially  accomplished,  the  diagnosis  of  asphyxia  is 
easily  made  from  the  failing  fetal  pulse,  the  cyanosis,  the  forcible  re- 
spiratory efforts,  and  the  relaxation  of  the  child's  muscles. 

Prognosis. — The  prognosis  depends  largely  upon  the  grade  of  the 
asphyxia,  although  the  cause  of  the  latter  is  of  still  greater  signifi- 
cance. Suspended  animation  which  is  not  accompanied  by  intra- 
uterine respiration  offers  the  best  prospects  for  resuscitation.  The 
chances  are  smaller  if  inspiration  has  occurred,  and  the  worst  prog- 
nosis is  afforded  by  the  occurrence  of  resi:)iration  when  the  nose  and 
mouth  are  occluded,  on  account  of  the  graver  derangement  of  the 
fetal  circulation,  and  the  more  abundant  pulmonary  extravasations. 
The  presence  of  aspirated  foreign  substances  clouds  the  j)rognosis  by 
interfering  with  efforts  at  artificial  respiration,  and  by  acting  as  the 
exciting  cause  of  atelectasis  and  of  lobular  pneumonia.  The  prognosis 
is  also  rendered  grave  by  the  occurrence  of  intracranial  haemorrhages. 
The  mortality  of  asphyxiated  children  in  the  first  eight  days  after 
delivery  is,  according  to  Poppel's  statistics,^  seven  times  greater  tlian 
that  of  children  born  unasphyxiated,  and  the  mortality  in  the  first 
week  in  direct  proportion  to  the  duration  and  gravity  of  the  sus- 
pended animation. 

Treatment. — The  indications  for  treatment  are  in  all  cases  to  clear 
out  the  air-passages,  to  restore  the  i/ritability  of  the  medulla,  to  in- 
crease the  force  of  the  heart-contractions,  and  to  relieve  the  plethora 
of  the  heart  and  of  the  blood-channels  of  the  thorax. 

In  cases  Avhere  the  muscular  tonus  is  preserved  these  indications  are, 
as  a  rule,  easily  fulfilled ;  aspirated  fluids  and  mucus  should  be  cleared 

*  Schultze,  op.  cit..  p.  127. 

t  Kristeller,  Monatsschr.  f.  Gehurtsk.,  Bd.  xxv.  1865,  p.  321 ;  Baetschee,  Ibid., 
Bd.  ix,  1857,  p.  294;  Mayer,  Ibid.,  Bd.  xxv,  1805,  p.  341. 
X  PoppEL,  op.  cit.,  p.  57. 


PROLAPSE  OF  THE  FUNIS,  ETC.  643 

from  the  fauces  with  the  finger.  If  the  nasal  passages  are  obstructed, 
mouth-to-mouth  insufflation  should  be  employed.  The  child  should  be 
made  to  cry  by  flagellation,  and  the  respiratory  movements  should  be 
further  stimulated  by  alternately  immersing  the  child  in  hot  and  cold 
water.  So  far  the  procedure  is  a  familiar  one,  but  in  a  good  number  of 
cases  we  know  that  in  a  few  days  the  skin  becomes  dusky,  the  heart 
action  feeble,  and  the  child  has  been  temporarily  restored  to  life  only 
in  the  end  to  die  of  atelectasis.  As  a  means  of  guarding  against  this 
fatal  sequence,  due  in  part  to  imperfect  expansion  of  the  lungs,  in 
part  to  lobular  congestion,  there  is  no  method  that  rivals  the  one  of 
Schultze. 

Schultze  directs  that  the  child  should  be  grasped  in  such  a  manner 
that  the  operator's  thumbs  rest,  on  either  side,  upon  the  anterior  tho- 
racic wall,  while  the  index-finger  occupies  the  axilla,  and  the  remaining 
fingers  are  placed  diagonally  across  the  back.  The  child  is  then  al- 
lowed to  hang  at  arm's  lengtli  between  the  knees  of  the  obstetrician,  its 
face  being  turned  to  the  front.  In  this  position  the  pectoral  muscles 
are  made  to  draw  the  superior  ribs  upward,  the  abdominal  muscles 
draw  the  inferior  ribs  downward,  and  the  weight  of  the  liver  causes  the 
descent  of  the  diaphragm.  By  this  means  the  capacity  of  the  chest  is 
increased,  and  inspiration  is  produced.  The  child  is  next  swung  up- 
ward, until  the  arms  of  the  operator  reach  an  almost  horizontal  posi- 
tion. The  swinging  motion  is  then  arrested,  flexion  occurs  in  the 
child's  lumbar  spinal  region,  its  head  is  directed  downward,  and  its 
lower  extremities  fall  slowly  toward  the  obstetrician  until  the  whole 
weight  of  its  body  rests  upon  his  thumbs.  In  this  way  the  chest  and 
abdomen  are  powerfully  compressed,  the  diaphragm  is  forced  upward, 
and  an  efficient  expiration  results,  and  any  retained  adventitious  mat- 
ters are  expelled  from  the  air-passages.  An  inspiration  is  now  pro- 
duced by  reversing  the  direction  of  the  swing  and  returning  the  child 
to  its  former  position  of  complete  extension,  by  which  manoeuvre  the 
chest  is  made  to  expand  and  the  diaphragm  to  descend. 

By  this  method  not  only  is  good  aeration  of  the  lungs  secured,  but 
the  forcible  expiration  expels  the  materials  aspirated  from  the  bronchial 
tubes.  A  still  more  important  action,  according  to  Schultze,  is  the  re- 
lief of  the  overloaded  vessels  as  a  result  of  the  compression  of  the  entire 
thoracic  contents.  Thus,  as  expiration  is  produced  by  the  upward 
swing,  the  blood  is  pressed  from  the  left  ventricle  into  the  aorta,  and 
from  the  right  auricle  into  the  right  ventricle.  The  emptying  of  the 
left  ventricle  makes  room  for  the  contents  of  the  left  auricle,  and  per- 
mits the  return  current  from  the  pulmonary  veins.  From  the  right 
ventricle  the  surplus  blood  finds  a  passage  into  the  aorta  through  the 
ductus  arteriosus.  With  the  inspiratory  swing  blood  is  aspirated  from 
the  peripheral  vessels  into  the  blood-channels  of  the  thorax.  The  as- 
pirated blood  is,  however,  venous,  as  the  semilunar  valves  prevent  re- 


g^^  THE  PATHOLOGY  OP  LABOR. 

gurgitation  from  the  aorta.  By  alternating  the  expiratory  and  in- 
spiratory swinging  movements  the  pump-working  of  the  heart  is 
mechanically  set  in  action.  As  the  blood-streams  pass  through  the 
heart  cavities,  the  systole  increases  in  force  and  the  arterial  tension 
is  restored. 

In  cases  of  deep  asphyxia,  in  which  muscular  tonicity  is  lost,  and 
the  heart  movements  are  scarcely  perceptible,  the  methods  at  first  em- 
ployed should  involve  the  minimum  degree  of  disturbance  to  the  child. 
Active  movements  are,  as  a  rule,  speedily  followed  by  the  extinction  of 
heart  pulsations. 

The  child  should  be  laid  upon  a  table  and  covered  warmly.  After 
clearing  the  fauces  and  nasal  passages  a  No.  8  English  elastic  catheter 
should  be  passed,  under  the  guidance  of  the  fingers  of  the  left  hand, 
through  the  larynx  into  the  trachea,  and  aspirated  matters  should  be 
carefully  removed  by  suction.  Meantime,  at  intervals  insufflations 
through  the  tube  into  the  bronchial  tubes  should  be  employed.  After 
each  insufflation  the  chest  walls  should  be  compressed  with  the  hand, 
to  produce  expiration.  By  this  means,  little  by  little,  the  blood  re- 
ceives oxygen,  and  the  returning  irritability  of  the  medulla  is  mani- 
fested by  occasional  spontaneous  respiratory  movements.  When  the 
color  returns  to  the  skin,  and  the  heart's  action  is  restored,  artificial 
respiration  should  be  maintained,  at  first  by  means  of  Sylvester's 
method,  which  is  preferable  to  that  of  Schultze  in  feeble  children,  as 
it  involves  less  exposure  and  less  violent  manipulations.  In  Sylvester's 
method  *  the  child  is  placed  upon  its  back  with  the  shoulders  raised 
sufficiently  to  prevent  the  chin  from  falling  forward  on  the  breast. 
The  tongue  is  drawn  forward  to  maintain  a  free  entrance  of  air  into 
the  windpipe.  To  imitate  the  movements  of  deep  inspiration,  the 
operator  grasps  the  arms  above  the  elbows,  and,  raising  them  upward 
by  the  sides  of  the  head,  he  extends  them  gently  and  steadily  upward 
and  forward  for  a  few  moments.  At  the  same  time  the  feet  should  be 
fixed.  According  to  Champneys,  the  effect  produced  is  more  than 
twice  as  great  when  the  arms  are  everted  as  when  the*  arms  are  in- 
verted. This  he  attributes  to  the  mode  of  insertion  of  the  pectoralis 
major  muscle  into  the  outer  lip  of  the  bicipital  groove,  eversion  natu- 
rally rendering  this  more  tense.  Expiration  is  effected  by  turning 
down  the  arms  and  pressing  them  gently  but  firmly  against  the  sides 
of  the  chest.  When  the  process  has  been  repeated  a  few  times,  the 
warm  bath  should  be  employed  to  prevent  undue  refrigeration  of  the 
cutaneous  surface.  The  method  described  should  be  alternated  with 
the  baths  until  spontaneous   respiration  is  maintained  or  the  case  be- 

*  Sylvester,  The  Discovery  of  the  Physiological  Method  of  inducing  Respira- 
tion in  Cases  of  Apparent  Death  from  Drowning,  Chloroform,  Still-birth,  Noxious 
Gases,  3d  ed..  1853  ;  The  True  Physiological  Method  of  restoring  Persons  Appar- 
ently Drowned  or  Dead,  and  of  resuscitating  Still-born  Children,  London,  1858. 


PROLAPSE   OF  THE   FUNIS,   ETC.  645 

comes  hopeless.  As  the  circulation  improves,  the  swinging  movements 
of  Schultze  may  often  be  employed  with  advantage.  In  prematurely  de- 
livered asphyxiated  children  these  methods  are  inapplicable,  since  the 
thoracic  walls  are  so  yielding  as  not  to  undergo  the  changes  of  form 
requisite  to  the  success  of  the  methods  described.  In  such  cases  insuf- 
flation, through  the  catheter,  following  aspiration,  of  the  foreign  bodies 
in  the  air-passages,  is  the  oi^y  available  treatment.  If  the  efforts  at 
resuscitation  be  successful,  the  child  must,  for  the  first  few  days  after 
its  birth  be  kept  particularly  warm  and  be  regularly  nourished.* 

Collapse  and  Sudden  Death  during  Labor  and  Childbed. 

We  have  already  had  frequent  occasion  to  mention  collapse  during 
or  following  labor  as  a  sequence  of  hemorrhage,  or  of  injuries  to  which 
the  genital  passages  have  been  subjected.  Syncope  is  not  an  uncom- 
mon result  of  exhaustion  following  prolonged  labor,  or  even  normal 
labor  in  women  with  exceptionally  sensitive  nervous  organizations. 
Again,  it  may  be  caused  by  the  cerebral  anaemia  produced  by  the  re- 
cession of  blood  from  the  nerve-centers  when  the  intra-abdominal 
pressure  is  suddenly  diminished  by  the  rapid  emptying  of  the  uterus. 
Temporary  syncope,  if  followed  by  complete  restoration  of  the  normal 
circulation,  has  no  positive  prognostic  significance.  Where,  however, 
the  pulse  continues  feeble  and  rapid,  it  should  be,  even  in  the  ab- 
sence of  other  grave  symptoms,  a  subject  of  profound  concern.  The 
arteries  then  gradually  become  empty,  while  the  large  venous  trunks 
fill  with  blood,  and  the  sluggish  current  predisposes  to  the  formation 
of  thrombi. 

Apart  from  such  rare  accidents  as  ceVebral  apoplexy,  or  heart  rupt- 
ure, or  fatal  endings  from  hemorrhage,  from  pulmonary  congestions 
and  oedema,  from  eclampsia,  from  inversion  and  rupture  of  the  uterus, 
and  acute  septicaemia,  the  causes  of  sudden  death  are  to  be  found  in 
pulmonary  embolism,  in  the  entrance  of  air  into  the  circulation,  and  in 
shock. 

On  Thrombosis  and  Embolism. — Thrombi  owe  their  importance  to 
the  disposition  they  possess  to  disintegrate  and  form  emboli,  which  are 
swept  along  by  the  circulation  until  arrested  by  the  diminished  caliber 
of  the  peripheral  vessels.  A  small  clot  forming  in  the  left  side  of  the 
heart  may  block  up  an  artery  in  the  brain  or  in  either  an  upper  or  lower 
limb.  The  symptoms  of  the  lesion  in  the  latter  case  are  the  absence 
of  pulsation  in  the  artery  below  the  thrombus,  with  pain,  coldness  of 
the  surface,  paralysis  of  the  nerves  of  motion  and  sensibility  if  the 

*  The  substitution  of  Sylvester's  method  for  those  of  Marshall  Hall  and  Schroe- 
der,  as  given  in  the  first  edition  of  this  work,  is  due  to  the  very  careful  and  satis- 
factory investigations  of  Francis  Henry  Charapneys  in  reference  to  the  amount  of 
ventilation  secured  by  the  dififerent  methods  of  artificial  respiration.  (Med.-Chir. 
Trans.,  vol.  Lxiv.) 


646 


THE  PATHOLOGY  OP  LABOR. 


arterial  obstruction  be  sudden  and  complete,  and  in  some  cases  gan- 
grene of  the  extremity  affected.* 

Of  much  more  common  occurrence  are  venous  thrombi.  Indeed, 
it  may  be  stated  that  thrombosis  of  the  veins  furnishes  the  most  fre- 
quent cause  of  sudden  death  in  labor  and  during  the  puerperal  period. 
As  a  rule,  the  clotting  takes  place  in  the  femoral,  the  pelvic,  or  the 
uterine  veins.  Spiegelberg  f  states  that  the  emboli  which  become  de- 
tached during  or  shortly  after  labor  proceed  from  clots  formed  at  the 
site  of  the  placenta. 

When  the  placenta  is  partially  detached  during  labor,  or  the  uterus 
does  not  properly  contract  after  the  birth  of  the  child,  sudden  haemor- 
rhage, followed  by  syncope  or  marked  weakening  of  the  heart's  action, 
may  lead  to  the  formation  of  large,  soft  clots,  extending  from  the  open 
mouths  of  the  sinuses  in  the  direction  of  the  heart.  These,  by  sudden 
movements,  by  the  douche,  or  under  a  powerful  contraction,  such  as 
oftentimes  follows  the  rupture  of  the  membranes  or  the  expulsion  of 
the  foetus,  may  be  set  adrift  from  their  moorings,  and  be  washed  up- 
ward through  the  vena  cava  to  the  right  side  of  the  heart,  and  thence 
to  the  branches  of  the  pulmonary  artery. 

It  has  been  assumed,  though  not  without  question,  that,  owing  to 
the  large  proportion  of  fibrin  in  the  blood  during  pregnancy  and  child- 
bed, it  is  possible,  when  the  heart's  action  is  feeble,  for  spontaneous 
coagulation  to  take  place  in  the  pulmonary  artery.  This  theory, 
originally  broached  by  Meigs,  has  been  warmly  supported  by  Playfair 
and  Barker.  Clinically,  many  striking  facts  have  been  adduced  in  its 
support.  Playfair  argues  that,  when  dyspnoea  precedes  phlegmasia 
doleus,  the  same  causes  which  have  led  to  throml)osis  of  the  femoral 
veins  have  antecedently  been  at  work  in  the  formation  of  coagula  in  the 
pulmonary  artery.  But  the  post-mortem  evidence  of  such  a  connexus 
is  not  conclusive.  Dr.  Mary  Putnam  Jacobi  has  reported  the  case 
of  a  patient,  dying  five  hours  after  labor,  where  precordial  oppression 
and  dyspncea  had  been  marked,  and  yet  no  lesions  whatever  were  found 
at  the  autopsy  to  account  for  these  symptoms.  Nor  is  it  possible, 
when  we  consider  the  frequency  with  which  thrombosis  of  the  uterine 
veins  precedes  that  of  the  veins  of  the  thigh,  to  be  sure,  in  the  absence 
of  ^  post-mortem  examination,  that  the  dyspnoea  observed  by  Pla^-fair 
may  not  have  been  due  to  an  embolus  from  a  clot  formed  in  a  uterine 
vessel.  I  would  not,  however,  deny  the  possibility  of  Playfair's  hypothe- 
sis. I  only  wish  to  emphasize  the  fact  that,  so  far  as  the  evidence  goes, 
it  lacks  the  positiveness  of  a  scientific  demonstration.  According  to 
all  ordinary  experience,  the  force  of  the  blood-current  in  the  pulmonary 
artery,  except  in  the  death  agony,  is  sufficient  to  prevent  spontaneous 

*  Barker,  The  Puerperal  Diseases,  p.  257 ;  Barnes,  Thrombosis  and  Emboli  of 
Lymg-in  Women,  Obst.  Trans.,  vol.  iv,  p.  30. 
t  Spiegelberg,  loc.  cit.,  p.  661. 


PROLAPSE  OF  THE   FUNIS,  ETC.  647 

coagulation  from  taking  place.  Virchow  has,  however,  pointed  out 
that  any  of  the  few  minor  veins  opening  into  the  right  auricle  may  be 
the  seat  of  the  primary  thrombus,  and  give  rise  to  a  large  secondary 
thrombus  within  the  auricle.     (Savage.) 

The  symptoms  of  stoppage  in  a  large  pulmonary  vessel  are  intense 
dyspno?a,  air-hunger  (to  use  an  expressive  German  term),  fluttering 
heart-action,  a  feeble,  rapid  pulse,  a  cold  skin,  and  striking  pallor  of 
the  countenance.  Death  may  follow  in  a  few  minutes,  or,  where  the 
main  trunk  is  free,  the  more  violent  symptoms  may  in  the  course  of  a 
half-hour  subside,  to  return,  however,  with  the  slightest  movement  or 
without  apparent  cause,  the  patient  dying  in  a  few  days  from  abnormal 
lowering  of  the  temperature,  from  dyspnoea,  and  cyanosis ;  or,  after  a 
succession  of  attacks,  the  thrombus  may  be  absorbed,  and,  as  I  have 
once  seen,  complete  recovery  may  take  place. 

The  Entrance  of  Air  into  the  Circulation.*— The  passage  of  air  from 
the  uterine  cavity  into  the  circulation  is  rendered  possible  by  the 
presence  of  open  sinuses,  or  of  sinuses  closed  by  soft,  easily  detached 
thrombi.  These  conditions  are  always  present  previous  to  delivery  in 
case  of  partial  separation  of  the  placenta,  and  in  the  puerperal  state, 
especially  in  the  latter,  when,  owing  to  debility  resulting  from  the 
undue  prolongation  of  labor,  the  expulsion  of  the  ovum  has  been  fol- 
lowed by  imperfect  retraction. 

Air  may  be  forcibly  driven  into  the  uterus  by  means  of  the  uterine 
or  even  the  vaginal  douche.  For  this  veason  the  siphon  syringe  should 
be  discarded  from  midwifery  practice.  The  objection  to  the  continu- 
ous stream  furnished  by  a  vessel  placed  at  a  height  above  the  patient, 
based  upon  the  insufficient  force  of  the  current,  is  purely  theoretical. 

It  is  not  necessary  that  the  nozzle  of  the  syringe  should  be  intro- 
duced directly  into  the  uterine  cavity  for  accidents  to  occur.  AVienerf 
has  reported  from  Spiegelberg's  clinic  a  case  where  collapse  followed 
the  use  of  the  vaginal  douche,  though  the  tube  was  free  from  air,  the 
hydrostatic  pressure  having  forced  air  which  had  previously  entered  the 
vagina  up  into  the  uterus.  When,  therefore,  the  douche  is  employed 
to  induce  premature  labor,  the  stream  should  at  first  be  propelled 
gently,  and  the  vulva  should  be  parted  to  permit  the  egress  of  con- 
tained air. 

Less  familiar  than  these  cases  of  forced  air  injection  are  well- 
accredited  instances  of  spontaneous  entrance  of  air  into  the  uterine 
sinuses.  This  accident  is  rendered  possible  by  the  diminution  of  the 
intra-abdominal  pressure  in  certain  body  postures.  Of  these,  the 
three  familiar  to  us  through  gynaecological  experiences  are,  respectively, 

*  Vide  Kezmarsky,  Ueber  Lufteintritt  in  die  Bhitbahnen  durch  den  puerperal. 
Uterus.  Avch.  f.  Gynaek.,  vol.  xiii,  p.  200. 

f  WiEXER,  Zur  Frage  der  kiinstlichen  Friihgeburt  bei  engem  Becken,  Arch,  fiir 
Gynaek..  vol.  xiii,  p.  94. 


g^g  THE  PATHOLOGY  OF  LABOR. 

the  knee-cliest,  the  latero-prone,  and  the  lithotomy  positions.  In  child- 
birth, under  favoring  conditions,  the  sudden  rupture  of  the  membranes 
which  had  previously  distended  the  vagina,  or  the  rapid  extraction  of 
the  child,  may  be  followed  by  the  ingress  of  air  into  the  uterus  itself, 
in  some  cases  doubtless  the  recession  of  the  uterus  after  its  evacuation 
favoring  the  occurrence  of  the  accident.  The  entrance  of  air  into  the 
uterus  does,  of  necessity,  do  harm,  or  the  harm  may  be  limited  to  the 
production  of  endometritis;  still  there  are  recorded  cases  where  the 
aspiration  of  air  has  been  followed  by  almost  instant  death. 

The  post-mortem  examinations  of  cases  of  death  from  air  entering 
the  uterine  sinuses  show  but  little  blood  in  the  left  side  of  the  heart ; 
frothy  blood  from  the  cut  surfaces  of  the  uterus ;  air  in  the  uterine 
veins,  the  vena  cava,  the  right  side  of  the  heart,  and  at  the  orifice  of 
the  pulmonary  artery ;  the  lungs  anaemic,  and  containing  frothy  serum ; 
the  brain  pale  and  infiltrated  with  serum. 

Corresponding  to  these  anatomical  conditions,  the  hands  during 
life  were  cold,  the  pulse  scarcely  perceptible,  the  face  blue  and  livid, 
consciousness  was  lost,  and  the  respirations  were  labored  and  jerky, 
with  all  the  symptoms  of  intense  dyspna3a. 

Nerve  Exhaustion  and  Shock. — Twenty  years  ago  these  pathological 
states  played  a  conspicuous  part  in  the  etiology  of  sudden  death  during 
childbirth.  Now  the  fashion  has  changed.  Such  terms  as  "  nervous 
apoplexy  "  and  "  idiopathic  asphyxia,"  which  were  employed  as  synon- 
ymous expressions,  belong  to  an  almost  forgotten  nomenclature. 
None  the  less  the  need  remains  to  account  for  a  class  of  cases  in  which 
death  takes  place  without  recognizable  organic  lesions. 

Instances  of  death  attributed  to  heart  paralysis  are  to  be  found  in 
the  collections  of  McClintock  *  and  Mordret ;  f  but  to  these  objections 
have  been  made,  either  that  the  post-mortem  confirmation  of  the  diag- 
nosis was  lacking,  or  that  the  examination  was  lacking  in  the  com- 
pleteness necessary  to  shut  out  other  possible  causes  of  death.  Baart 
de  la  Faille,  J  however,  has  more  recently  collected  thirteen  cases  of 
collapse  in  which  the  occurrence  of  embolism  and  the  entrance  of  air 
could  with  every  probability  be  excluded.  Cases  where  the  absence  of 
all  symptoms  of  pulmonary  obstruction  furnish  certain  evidence  that 
neither  of  these  causes  was  operative  may  be  found  scattered  through 
medical  literature.* 

In  the  absence  of  visible  lesions,  or  the  characteristic  symptoms  of 
the  conditions  to  which  death  in  childbed  is  usually  referred,  we  have 

*  McClintock,  Dublin  Med.  Press,  1853. 
\  Mordret,  Mem.  Acad.  Med.,  1858. 

X  Baart  de  la  Faille,  vide  Synopsis  Monatsschr.  fiir  Geburtskunde,  vol.  xxv, 
p.  318. 

*  Vide  ease  reported  by  0.  T.  Schultze  in  American  Practitioner,  April,  1884. 
likewise  author's  paper  on  Sudden  Death  in  Labor  and  Childbed,  Journal  of  the 
American  Med.  Assoc,  for  recent  examples. 


PROLAPSE  OF  THE  FUNIS,  ETC.  649 

the  right  to  attribute  the  melancholy  issue  to  the  same  causes  which, 
outside  of  childbed,  produce  identical  phenomena.  In  the  torpid  form 
of  shock  the  features  are  pinched,  the  eyes  sunken  and  surrounded 
by  dark  rings,  the  skin  possesses  a  marble  pallor,  the  hands  and  lips 
are  blue,  the  extremities  are  cold,  sweat  stands  upon  the  brow,  the 
pulse  is  thready  and  scarcely  perceptible,  while,  in  contrast  to  cases  of 
pulmonary  obstruction,  the  breathing,  though  it  may  be  shallow,  is  not 
difficult  or  labored,  and,  in  spite  of  the  extreme  prostration  of  the 
physical  forces,  the  sphincters  remain  closed,  and  both  consciousness 
and  sensibility  are  preserved.  Sometimes  these  earlier  symptoms  are 
followed  by  a  stage  of  excitement  in  Avhich  the  face,  with  the  exception 
of  the  mucous  membranes,  becomes  reddened,  the  eyes  grow  bright, 
the  patient  becomes  restless,  complains  of  constant  thirst,  and  bids  her 
friends  farewell  in  anticipation  of  speedy  death ;  but,  in  spite  of  the 
reviving  color,  the  pulse  continues  too  rapid  to  be  counted,  the  skin 
never  regains  its  normal  temperature,  and  the  hopes  of  speedy  restora- 
tion to  health  are  dashed  by  the  gradual  or  sudden  suspension  of  the 
beatings  of  the  heart. 

Modern  pathological  investigation  refers  the  phenomena  of  shock 
to  a  reflex  paralysis  of  the  vaso-motor,  and  especially  of  the  splanchnic 
nerves,  whereby  the  great  mass  of  the  blood  is  withdrawn  from  the  sur- 
face, and  collects  in  the  trunks  of  the  coeliac,  the  mesenteric,  and  the 
renal  veins.  Hence,  the  skin  becomes  cold,  and  is  devoid  of  color  save 
at  the  points  where  a  bluish  hue  is  imparted  by  the  stagnant  blood  still 
lingering  in  the  veins ;  the  muscles,  deprived  of  blood,  feebly  respond 
to  the  impulses  of  the  will ;  the  empty  vessels  of  the  brain  explain  the 
sluggish  intelligence,  the  nausea,  the  vomiting,  and  the  indifference  of 
the  patient ;  and,  finally,  during  the  diastole,  the  heart,  pale  and  con- 
tracted, receives  but  little  blood,  and  the  radial  pulse  fades  to  nothing- 
ness because  of  the  corresponding  small  amount  of  fluid  propelled  dur- 
ing the  systole  into  the  arterial  vessels.* 

From  works  on  military  surgery  we  learn  that  it  is  in  the  defeated 
army,  among  homesick  soldiers,  at  the  close  of  a  wearisome  war,  after 
great  exertions  and  deprivations,  that  shock  is  developed  in  its  severest 
forms ;  that  the  finer  the  organization,  the  more  readily  the  manifesta- 
tions occur  ;  that  they  are  promoted  by  sudden  losses  of  blood,  and  are 
in  a  special  degree  evoked  by  abdominal  injuries. 

It  certainly  would  be  singular  if  similar  conditions  in  childbed  were 
not  followed  by  similar  results.  After  labor,  the  nervous  system  of  the 
woman  is  depressed  by  pain,  starvation,  and  loss  of  sleep.  The  sud- 
den emptying  of  the  uterus  is  followed  by  a  recession  of  blood  from 
the  head  to  the  venous  trunks  of  the  abdomen.  Haemorrhage,  followed 
by  weakening  of  the  heart's  action,  tends  still  further  to  increase  the 
venous  stasis.  In  the  old  days  of  torture,  shock  often  mercifully  put 
*  Fischer,  Ueber  den  Shok,  Volkmann's  Sararal.  klin.  Vortrage,  No.  x. 


Q^Q  THE  PATHOLOGY  OF  LABOR. 

an  end  to  the  victim's  anguish.  Women  in  childbirth  are  at  times 
subjected  to  pain  exceeding  that  of  the  rack  and  the  thumbscrew ;  and 
the  wonder  is  not  that  the  circulation  should  occasionally  show  signs 
of  marked  and  even  fatal  disturbance,  but  that  the  nervous  system,  at- 
tacked from  so  many  directions,  should,  in  the  rule,  triumph  over  the 
adverse  forces. 

Treatment. — The  treatment  of  pulmonary  embolism,  whether  due 
to  air  or  a  disintegrated  thrombus,  is  necessarily  for  the  most  part  pro- 
phylactic. The  proper  precautions  for  avoiding  the  accidents  described 
are  sufficiently  indicated  in  the  preceding  discussions  as  to  their  etiol- 
ogy. It  is  proper  to  remember  that  the  nervous  organization  of  woman 
loses  in  powers  of  resistance  as  the  penalty  of  a  higher  civilization  and 
of  artificial  refinement,  and  that  it  becomes,  therefore,  imperatively 
necessary  for  the  physician  to  guard  her  from  the  dangers  of  excessive 
and  too  prolonged  suffering.  Especially  I  would  raise  my  voice  in 
warning  against  the  current  opinion  that  the  length  of  the  first  stage 
of  labor  before  the  rupture  of  the  membranes  is  a  matter  of  indiffer- 
ence. In  pulmonary  embolism  the  violence  of  the  symptoms  at  the 
outset  of  the  attack  is  often  out  of  proportion  to  the  real  gravity  of  the 
lesion.  A  small  embolus  or  air  entering  the  lungs,  finely  subdivided, 
may  produce  symptoms  of  dyspnoea  which  may  be  of  temporary  dura- 
tion. In  all  cases,  therefore,  warmth  should  be  applied  to  the  surface, 
and  every  effort  should  be  made  to  maintain  tiie  action  of  the  heart. 
To  this  end  injections  of  ether  beneath  the  skin,  and  of  ammonia  into 
the  veins,  are  to  be  counted  as  most  powerful  adjuvants.  In  shock, 
opium,  atropia,  and  digitalis  are  theoretically  indicated,  and  yet  large 
doses  of  the  latter  drug,  as  have  been  sometimes  recommended,  are 
not  unattended  with  risk,  and  may  precipitate  the  final  catastrophe. 

Extraction  of  the  Child  in  Case  of  Real  or  Apparent  Death 
OF  the  Mother  during  Pregnancy  or  Labor. 

Death  of  the  mother  during  pregnancy  or  labor  may  be  threatened, 
or  may  actually  result,  either  suddenly  or  slowly,  from  various  morbid 
conditions  which  have  been  previously  considered.  Although  sudden 
death  of  the  mother  is  more  frequent  at  the  time  of  delivery,  in  con- 
sequence of  haemorrhage,  exhaustion,  eclampsia,  or  rupture  of  the  ute- 
rus, it  may  occur  at  any  time,  particularly  when  due  to  pulmonary  and 
cardiac  affections,  or  to  cerebral  embolism. 

It  is  our  present  object  to  consider  the  methods  of  treatment  best 
adapted  to  the  preservation  of  the  child's  life  in  those  cases  necessa- 
rily attended  by  death  of  the  mother,  and  to  the  preservation  of  both 
mother  and  child  whenever  there  is  any  probability  of  such  a  result. 
Our  inquiry  may  therefore  be  limited  to  those  cases  in  which  the 
child  is  unquestionably  living,  and  its  viability  undoubted.     While  the 


PROLAPSE  OF  THE  lUNIS,   ETC.  651 

majority  of  recent  authors  upon  this  subject  have  recognized  the  pro- 
priety of  adopting  prompt  measures  for  the  immediate  extraction  of 
the  child  after  the  mother's  decease,  the  same  unanimity  has  not  pre- 
vailed either  in  regard  to  the  propriety  of  operative  interference  before 
the  mother's  death,  or  as  to  the  most  appropriate  methods  of  opera- 
tion. Schroeder  *  is  content  with  the  statement  that,  in  case  of  ma- 
ternal demise  during  parturition,  efforts  should  be  made  to  extract  the 
fa3tus  per  vias  nafnrales  by  version  or  the  forceps.  In  the  event  of 
failure  to  accomplish  delivery  by  this  method,  he  advises  immediate  re- 
sort to  the  Caesarean  section.  SiDiegelberg  f  recommends  the  Caesarean 
section  for  all  cases  of  maternal  death,  excepting  those  occurring  in 
the  second  stage  of  labor,  as  the  surest  method  of  preserving  fetal  life. 
He  makes  no  provision  for  those  cases  in  which  the  mothers  are  appar- 
ently dead,  although  actually  in  a  state  of  syncope  or  asphyxia.  Both 
he  and  Max  Runge  J  recommend  the  Cesarean  section,  even  in  cases 
of  impending  death  of  the  mother,  in  the  child's  interest,  and  dispar- 
age efforts  at  extraction  through  the  natural  passages.  Duer  ^  con- 
cludes («)  that  no  operative  procedure  should  be  undertaken  until  there 
is  absolute  certainty  of  the  mother's  death ;  (b)  that,  death  of  the  mother 
being  assured,  the  Caesarean  section  should  be  performed  with  dispatch 
if  the  fetal  head  be  above  the  pelvic  brim ;  (c)  that,  if  the  head  have 
engaged  in  the  brim,  the  question  of  resort  to  the  Ca?sarean  section  or 
to  extraction ^^er  vias  nafnrales  becomes  debatable.  He  condemns  the 
practice  advocated  by  Rizzoli  and  Esterle,  of  resorting  to  forced  de- 
livery when  the  mother's  death  is  imminent. 

One  of  the  most  recent  and  comprehensive  articles  on  the  subject 
of  artificial  delivery  jper  vias  naturales  is  that  of  Thevenot,||  who,  re- 
ferring its  original  introduction  to  Schenk  and  Eigaudeaux,  and  its 
development  to  Rizzoli,  Heymann,  and  Depaul,  ardently  advocates  its 
adoption,  to  the  exclusion  of  the  Cesarean  section.  This  method  he 
declares  to  be  applicable  {a)  to  those  cases  with  normal  pelvic  confor- 
mation in  which  the  mother  is  dead,  the  labor  somewhat  advanced,  the 
OS  dilated  or  dilatable,  and  the  head  at  the  superior  strait ;  {h)  to  cases 
in  which  labor  was  only  commencing,  or  had  not  begun  at  the  time  of 
death ;  (c)  to  cases  frequently  occurring,  according  to  the  author,  of 
apparent  death  of  the  mother  (her  real  condition  being  that  of  syn- 
cope), whether  labor  had  or  had  not  begun  at  the  time  of  her  apparent 
decease ;  and  {d)  to  cases  of  impending  maternal  death.  Thevenot's 
arguments  in  favor  of  the  method  of  treatment  under  consideration 

*  Schroeder,  Lehrbuch,  p.  712.  f  Spiegelberg,  Lehrbueh,  p.  269. 

X  Max  Runge,  Ueber  die  Berechtigung  des  Kaiserschnitts  an  der  Sterbenden 
und  der  mit  ihm  concnrrirenden  Entbindangs-Verfahren,  Ztschr.  fiir  Geburtsk. 
und  Gynaek.,  vol.  ix,  p.  245.        *  Duer,  Am.  Jour,  of  Obstet,  January.  1879,  p.  10. 

II  Thevesot,  De  I'acc.  artif.  par  les  voies  nat.  substit.  a  I'operation  eesar.  post- 
mortem, Ann.  de  Gynec,  tome  x,  October,  1878,  p.  257;  November,  1878,  p.  339; 
December,  1878,  p.  412. 


g52  THE  PATHOLOGY  OF  LABOR. 

are,  that  the  operation  may  be  more  promptly  resorted  to  than  the 
Caesarean  section,  the  preparations  for  and  hesitations  about  which  fre- 
quently occasion  fatal  delays ;  that  it  is  of  less  vital  importance  that 
the  death  of  the  mother  be  positively  ascertained  than  in  cases  of  Cae- 
sarean section ;  that  it  is  a  less  repulsive  proceeding ;  that  the  results 
are  bettfer  than  in  the  Caesarean  section ;  that  the  method  is  not  pro- 
ductive of  medico-legal  complications ;  and  that  it  affords  a  numerous 
class  of  parturient  women,  who  are  only  apparently  dead,  a  far  better 
chance  of  recovery  than  does  the  Cesarean  section.  Thevcnot  cites 
fifteen  cases  of  accoucliement  force  employed  upon  women  at  the  point 
of  death,  in  which  thirteen  infants  were  alive  at  birth,  and  six  lived 
permanently.  Five  of  the  fifteen  mothers,  who  were  apparently  mori- 
bund, recovered,  and  in  three  other  cases  the  original  diseases  were  re- 
tarded, and  their  most  distressing  symptoms  temporarily  relieved. 

Tympanites  Uteri. — If  air  enters  the  uterine  cavity  previous  to  the 
birth  of  the  child,  the  dangers  are  not  confined  to  its  passage  into  the 
venous  circulation.  Even  when  this  latter  accident  does  not  occur, 
the  patient's  condition  in  a  lingering  labor  is  perilous  in  the  extreme. 
The  essential  condition  for  the  admission  of  air  is  rupture  of  the  mem- 
branes. As  a  result  in  many  though  not  in  all  cases  untimely  re- 
spiratory efforts  are  excited  in  the  child.  In  very  rare  instances  it  is 
said  that  the  cry  of  the  child,  vayitus  uterinus^  has  been  heard  within 
the  nterus.  Death  speedily  follows  premature  respiration,  and,  under 
the  combined  influence  of  air,  heat,  and  moisture,  decomposition 
rapidly  develops.  *  The  gases  generated  by  putrefaction  are  some- 
times of  enormous  volume,  and  the  uterus  furnishes  a  tympanitic 
resonance  upon  percussion.  As  a  result  of  prolonged  labor,  of  the  dis- 
tention of  the  uterine  walls,  and  of  septic  poisoning,  the  pains  become 
feeble  and  the  patient  suffers  from  dyspnoea,  owing  to  the  pressure 
upon  the  diaphragm  by  the  enlarged  uterus  and  the  colon,  which  like- 
wise is  found  distended  with  gases.  A  stinking  discharge,  sometimes 
mingled  with  gas-bubbles  is  always  present. 

The  prognosis  depends  upon  the  intensity  of  the  process  and  the 
length  of  time  allowed  to  elapse  before  operative  measures  are  em- 
ployed to  remove  the  source  of  danger.  Of  sixty-four  women,  accord- 
ing to  Staude's  report,  thirty-two  died,  eighteen  had  severe  puerperal 
affections,  and  only  fourteen  recovered  without  further  complications. 
The  indications  for  treatment  are,  to  extract  the  child  as  soon  as  prac- 
ticable when  air  has  once  entered  the  uterine  cavity,  to  wash  out  the 
uterus  with  disinfectant  fluids,  to  use  all  available  means  to  secure 
continued  retraction  of  the  uterus,  and  follow  every  antiseptic  pre- 
caution during  the  puerperal  period. 

*  Staude  found  putrefactive  changes  developed  in  foetuses  born  from  three  to 
twenty-one  hours  after  the  access  of  air  to  the  uterus.  Ueber  den  Eintritt  von  Luft 
in  die  Gebarmutter,  Ztschr.  f .  Geburtsh.  und  Gynaek.,  Bd.  iii,  p.  204. 


DISEASES  OF  CHILDBED. 


CHAPTER  XXXV. 

PUERPERAL  FEVER. 

Definition. — Frequency. — Morbid  anatomy. — Endometritis  and  endocolpitis. — Me- 
tritis and  parametritis. — Pel  vie  and  diffused  peritonitis. — Phlebitis  and  phlebo- 
thrombosis. — Septicaemia. — Earlier  views  concerning  the  natui'e  of  puerperal 
fever. — The  nature  of  puerperal  fever  as  regarded  from  the  standpoint  of  mod- 
ern investigation. — General  symptoms. — The  symptoms  of  endometritis  and 
endocolpitis;  of  parametritis  and  perimetritis ;  of  general  peritonitis ;  of  sep- 
ticaemia lymphatica ;  of  septicfemia  venosa ;  of  pure  septica3mia. 

Definition. — Puerperal  fever  is  an  infections  disease,  due,  as  a  rule,  to 
the  septic  inoculation  of  the  wounds  which  result  from  the  separation 
of  the  decidua  and  of  the  placenta,  and  from  the  passage  of  the  child 
through  the  genital  canal  in  the  act  of  jaarturition. 

To  maintain  this  definition  it  is,  however,  necessary  to  group  by 
themselves  cases  of  childbed  fever  dependent  upon  causes  which  are 
operative  in  the  non-puerperal  condition,  though  the  latter  imparts  to 
those  causes  oftentimes  an  exceptional  activity  and  virulence.  In  this 
category  are  to  be  placed  especially  scarlatina,  typhus,  typhoid,  and  ma- 
larial fevers.  It  is  to  be  borne  in  mind  that  the  zymotic  fevers  may  pro- 
voke in  the  puerperal  woman  the  same  inflammatory  lesions  commonly 
associated  with  puerperal  fever.*  This  is  in  accordance  with  the  well- 
known  surgical  experience  that  a  febrile  paroxysm  from  any  cause  exerts 
an  unfavorable  influence  upon  a  wounded  surface. 

Like  all  brief  statements,  the  writer  is  well  aware  that  the  foregoing 
definition  is  necessarily  imperfect,  and  stands  in  need  of  further  lim- 
itations to  meet  the  requirements  of  exactness.  Exceptions,  however, 
either  apparent  or  real,  will  be  noted  hereafter  in  their  proper  connec- 
tions. 

Frequency. — In  a  careful  search  through  the  records  preserved  by 
the  Health  Department  of  New  York  city,  I  found  that  from  1868  to 
1875,  inclusive,  the  total  number  of  deaths  for  nine  years  was  248,533. 
Of  these,  3,342  were  from  diseases  complicating  pregnancy,  from  the 
accidents  of  child-bearing,  or  from  diseases  of  the  puerperal  state  ;  or, 
in  other  words,  1 :  75  of  all  the  deaths  occurring  during  that  period  was 

*  Hervieus,  Traite  clinique  et  pratique  des  maladies  puerperales,  pp.  1073  etseq. 


g^j.  DISEASES  OF  CHILDBED. 

the  result  of  the  ijerformance  of  what  we  are  in  the  habit  of  regarding 
as  a  physiological  function. 

The  deaths  from  miscarriage,  from  shock,  from  prolonged  labor, 
from  instrumental  delivery,  from  convulsions,  from  hasmorrhage,  from 
rupture  of  the  uterus,  and  from  extra-uterine  pregnancy,  and  deaths 
from  eruptive  fevers,  from  phthisis,  and  from  inflammatory  non-puer- 
peral affections  complicating  childbirth,  made  a  total  of  1,395,  or  about 
42  per  cent  of  the  entire  number.  The  remaining  1,94:7  cases,  vari- 
ously reported  as  puerperal  fever,  puerperal  peritonitis,  metro-peritoni- 
tis, phlebitis,  phlegmasia  dolens,  pyaemia,  and  septicemia,  represent  the 
very  serious  sacrifice  of  life  resulting  from  inflammatory  processes  which 
have  their  starting-point  in  the  generative  apparatus.  If  we  apply  the 
general  term  puerperal  fever  to  this  class  of  cases,  it  will  be  seen  that 
the  yearly  average  of  deaths  between  the  years  mentioned  was  215 -5, 
and  that  the  malady  was  the  cause  of  nearly  one  one-hundred-and- 
twenty-seventh  of  all  the  deaths  occurring  in  the  city. 

More  recently  statistics  have  been  prepared  for  me  from  the  same 
sources  by  my  friend  Dr.  Rutson  Maury  for  the  five  years  from  1885  to 
1889,  inclusive,  which  show  that  the  reported  deaths  from  puerperal 
sepsis  were  1,105,  or  an  annual  average  of  221. 

The  population  of  New  York  in  1870  was  942,292 ;  in  1875, 1,1G9,- 
305  ;  in  1885,  1,553,730  ;  in  1890,  1,755,292,  It  will  be  seen,  therefore, 
that  the  ratio  of  deaths  has  by  no  means  kept  pace  with  the  increase  of 
the  city's  population. 

A  portion  of  this  betterment  is  doubtless  attributable  to  reforms  in 
the  management  of  our  lying-in  hospitals.  "Whereas,  formerly  these 
institutions  furnished  nearly  one  sixth  of  the  fatal  cases  of  puerperal 
sepsis,  they  now,  when  properly  equipped  and  organized,  afford  the 
safest  places  of  refuge  for  parturient  women.  There  has  likewise  been, 
without  doubt,  an  improvement  in  results  among  the  well-to-do  classes. 
Among  these  there  is  a  widely  diffused  belief  that  puerperal  fever  is  a 
preventable  disease,  and  that  for  its  occurrence  tlie  physician  should  be 
held  responsible,  and  this  leads  to  greater  painstaking  on  the  part  of  the 
latter,  even  when  he  is  disinclined  to  accept  the  deductions  from  mod- 
ern scientific  teaching.  Among  the  poor,  in  their  own  homes,  I  do  not 
believe  that  the  dangers  of  childbed  have  been  perceptibly  lessened,  for 
in  Dr.  Maury's  statistics  it  appears  that  even  in  the  past  five  years  one 
tenth  of  the  deaths  in  women  between  the  ages  of  fifteen  and  forty-five 
are  due  to  causes  connected  with  childbirth,  and  that  one  twentieth  of 
the  deaths  among  women  in  the  child-bearing  period  are  due  to  puer- 
peral sepsis. 

Max  Boehr,*  in  his  now-famous  statistics,  reckons  that  one  thirtieth 
of   all   married  women  in  Prussia   die  in   childbed.     The   Puerperal 

*  Untersuchungen  iiber  die  Haufigkeit  des  Todes  im  Wochenbett  in  Preussen, 
Zeitschr.  f.  Geburtsk.  und  Gynaek,  vol.  iii,  p.  82. 


PUERPERAL  FEVER.  655 

Fever  Commission*  appointed  by  the  Berlin  Society  of  Obstetrics  and 
Gynaecology  arrived  at  the  conclusion  that  from  10  to  15  per  cent  of 
the  deaths  occurring  in  women  during  the  period  of  sexual  activity 
were  due  to  childbed  fever,  and  that  this  disease  destroyed  nearly  as 
many  lives  as  small-pox  or  cholera.  But  puerperal  fever  differs  from 
either  small-pox  or  cholera  in  that  the  latter  presses  largely  upon  the 
aged  and  the  very  young,  while  the  former  gathers  its  victims  exclu- 
sively from  a  selected  class — viz.,  from  women  in  adult  life,  the  moth- 
ers of  families,  whose  loss,  as  a  rule,  is  a  public  as  well  as  a  private 
calamity. 

Before  proceeding  to  consider  the  nature  of  puerperal  fever,  it  is 
desirable  to  first  recall  the  anatomical  lesions  with  which  it  is  associated. 
These,  it  will  be  found,  are  for  the  most  part  inflammatory  processes, 
having  their  starting-point  in  injuries  of  the  genital  passage  produced 
by  parturition,  complicated  in  many  cases  by  septic  changes  in  the  blood, 
by  secondary  degeneration  of  parenchymatous  organs,  and  at  times  by 
phlegmonous  and  erysipelatous  affections  in  remote  as  well  as  in  the  ad- 
jacent serous  and  cutaneous  tissues. 

Morbid  Anatomy. — The  primary  lesions  connected  with  puerjjeral 
fever  are  so  various  that  the  student  will  find  it  convenient  to  classify 
them  according  as  they  are  situated  in  the  mucous  membrane  of  the 
utero-vaginal  canal,  the  parenchyma  of  the  uterus,  the  pelvic  cellular 
tissue,  the  peritonasum,  the  lymphatics,  or  the  veins.  Not,  indeed, 
that  such  an  arrangement  is  strictly  in  accordance  with  clinical  expe- 
rience— as  a  rule,  the  inflammatory  processes  are  rarely  limited  to  a 
single  tissue — but  because  the  prognosis  and  treatment  are  determined 
in  great  measure  by  the  tissue-system  which  is  predominantly  affected. 
The  significance  of  puerperal  inflammations,  wherever  seated,  likewise 
depends  upon  whether  they  are  local  and  circumscribed  or  whether 
they  present  a  spreading  character. 

Personally,  I  have  found  the  following  classification,  based  on  that 
of  Spiegelberg,f  of  great  utility  as  a  means  of  keeping  in  mind  the 
principal  points  to  Vv'hich  inquiry  should  be  directed  in  estimating  the 
significance  of  the  febrile  conditions  of  childbed : 

1.  Inflammation  of  the  genital  mucous  membrane. — Endocolpitis, 
endometritis,  and  salpingitis. 

a.  Superficial,  suppurative. 
h.  Ulcerative  (diphtheritic). 

2.  Inflammation  of  the  uterine  parenchyma,  and  of  the  subserous 
and  pelvic  cellular  tissue. 

a.  Exudation  circumscribed. 

b.  Phlegmonous,  diffused ;  with  lymphangitis  and  j)ya3mia  (l3'm- 
phatic  form  of  peritonitis). 

*Zeitschr.  f.  Geburtsk.  und  Gynaek,  vol.  iii,  p.  1. 

f  Ueber  das  Wesen  des  Puerperalfiebers,  Volkmann's  Samml.  klin.  Vortr.,  No.  3, 


656 


DISEASES  OF  CHILDBED. 


3.  Inflammation  of  the  peritonaeum  covering  the  uterus  and  its 
appendages. — Pelvic  peritonitis  and  diffused  peritonitis. 

4.  Phlebitis  uterina  and  para-uterina,  with  formation  of  thrombi, 
embolism,  and  pyaemia. 

5.  Pure  septicsemia. — Putrid  absorption. 

Endocolpitis,  Endometritis  and  Salpingitis.— In  the  superficial  sup- 
purative form  of  inflammation  the  mucous  membrane  of  the  vagina  is 
swollen  and  hypertemic,  the  papillae  are  enlarged,  and  the  discharge  is 
profuse ;  in  the  vaginal  portion  of  the  cervix  the  labia  uterina  are 
oedematous  and  covered  with  granulations  Avhich  bleed  at  the  slightest 
touch  ;  in  the  cavity  of  the  body  there  are  increased  transudation  of 
serum  and  abundant  pus-formation.  The  deep  structures  of  the  uterus 
are  usually  not  affected.  Sometimes  the  inflammation  extends  to  the 
tubes — scdpingitis — or,  passing  outward  through  the  fimbriated  ex- 
tremities, it  may  spread  over  the  adjacent  peritonaeum. 

The  small  wounds  at  the  vaginal  orifice  are  at  times  converted  into 
ulcers  with  tumefied  borders.  These  so-called  puerperal  ulcers  are 
covered  with  a  grayish-white  layer.  They  are  associated  usually  with 
oedematous  swelling  of  the  labia.  Under  favorable  sanitary  conditions 
the  layer,  which  consists  in  the  main  of  pus-cells  and  necrosed  tis- 
sue, is  thrown  off,  and  the  surface  heals  by  granulation.  The  ulcera- 
tive form  of  inflammation  is  very  rare  outside  of  crowded  hospitals. 

Diphtheritic  ulcers  are  situated  with  greatest  frequency  in  the 
neighborhood  of  the  posterior  commissure,  or  around  the  vaginal  ori- 
fice. In  rarer  instances  they  are  found  upon  the  anterior  wall  and  in 
the  fornix  of  the  vagina,  in  the  cervix,  and  upon  tlie  site  of  the  pla- 
centa. The  borders  are  red  and  jagged ;  the  base  is  covered  with  a 
yellowish-gray,  shreddy  membrane  ;  the  secretion  is  purulent,  alkaline, 
and  fetid ;  and  the  adjacent  tissues  are  cedematous.  From  the  vulva 
they  may  extend  to  the  perinteum,  or  pursue  a  serpiginous  course 
down  the  thighs.  In  the  uterus  and  about  the  cervix  they  vary  as  re- 
gards size,  and  are  either  of  a  rounded  shape  or  form  narrow  bands. 
The  intervening  portions  of  tissue  which  have  not  undergone  destruct- 
ive changes  swell  and  stand  out  in  strong  relief.  Where  the  entire 
inner  surface  has  become  necrosed,  it  is  often  covered  with  a  smeary, 
chocolate-brown  mass,  which,  when  washed  away  with  a  stream  of 
water,  leaves  exposed  either  the  deepest  layer  of  the  mucous  membrane 
or  the  underlying  muscular  structures. 

Not  infrequently  the  inflammatory  process  extends  to  the  tubes, 
which  swell  and  become  tortuous.  The  tubal  canal  fills  with  pus,  or  in 
diphtheritic  forms,  with  a  fetid,  brownish,  ichorus  material.  The  dis- 
tention is  most  marked  at  the  ampulla?.  Usually  the  fimbriated  ex- 
tremities of  the  tubes  are  closed  by  adhesive  inflammation.  Sometimes, 
however,  they  remain  patent,  and  permit  the  purulent  secretion  to 
spread  over  the  adjacent  peritonaeum. 


PUERPERAL   FEVER.  657 

Metritis  and  Parametritis. — In  ulcerative  endometritis,  and  even  in 
the  extreme  suppurative  form,  the  parenchyma  of  tlie  uterus  likewise 
becomes  involved.  The  changes  which  are  designated  under  the  term 
metritis  consist,  in  the  first  place,  of  oedematous  infiltratiou  of  the  tis- 
sues. As  a  consequence,  the  organ  contracts  imperfectly  and  becomes 
soft  and  flabby,  so  that  sometimes,  upon  post-mortem  examination,  it 
bears  the  imprint  of  the  intestines. 

In  diphtheritic  endometritis,  the  destructive  process  may  attack 
the  muscular  tissue,  and  give  rise  to  losses  of  muscular  substance — 
a  condition  known  as  necrotic  endometritis  or  putrescence  of  the 
uterus. 

Inflammatory  changes  are  rarely  lacking  in  the  intermuscular  con- 
nective tissue,  which  exhibits,  in  j^laces,  serous  or  gelatinous  infiltration, 
with,  afterward,  pus-formation,  and  with  here  and  there  small  abscesses. 
The  sero-purulent  infiltration  of  the  connective  tissue  is  specially 
marked  beneath  the  peritoneal  covering  of  the  uterus  either  behind  or 
along  the  sides  at  the  attachment  of  the  broad  ligaments.  In  the 
same  situations  the  lymphatics,  which  normally  are  barely  perceptible 
to  the  naked  eye,  are  sometimes  enlarged  to  the  size  of  a  quill,  and  are 
characterized  by  varicose  dilatations  occurring  singly  or  presenting  a 
beaded  arrangement.  In  the  substance  of  the  uterus  the  dilated  ves- 
sels are  liable  to  be  mistaken  for  small  abscesses.  The  pus-like  sub- 
stance contained  in  the  lymphatics  is  composed  of  pus-cells  and  of 
micrococci.  From  the  cellular  tissue  surrounding  the  vagina,  or  that 
beneath  the  peritoneal  covering  of  the  uterus,  the  inflammation  may 
spread  by  contiguity  of  tissue  between  the  folds  of  the  broad  ligament, 
and  thence  pass  upward  to  the  iliac  fossae.  Usually  the  process  is  uni- 
lateral. After  the  inflammation  has  crossed  the  linea  terminalis  it  may 
take  a  forward  direction,  above  the  sheath  of  the  ilio-psoas  muscle,  to 
Poupart's  ligament,  or  it  may  creep  upward,  following  the  course 
according  to  the  side  affected,  of  the  ascending  or  descending  colon, 
to  the  region  of  the  kidney.  It  is  rare  for  inflammation  of  the  cellular 
tissue  to  travel  around  the  bladder  to  the  front.  In  such  cases  it  pur- 
sues its  course  between  the  walls  of  the  bladder  and  the  uterus,  and 
along  the  round  ligament  to  the  inguinal  canal.  In  a  few  cases  the 
cellulitis  mounts  above  Poupart's  ligament,  between  the  peritonaeum 
and  the  abdominal  wall. 

The  course  of  the  inflammation  is  not  simply  fortuitous,  but  fol- 
lows prearranged  pathways  in  the  connective  tissue.  Konig*  and 
Schlesinger  f  have  shown  that  when  air,  water,  or  liquefied  glue  is 
forced  into  the  cellular  tissue  between  the  broad  ligaments  the  injected 
mass  has  a  tendency  to  invade  the  iliac  fossae.  In  Schlesinger's  ex- 
periments, if  the  canula  of  the  syringe  was  inserted  into  the  anterior 

*  Arch,  fler  Heilkunde,  3  Jahrg.,  1862. 
t  Gvnaekologische  Studien,  No.  1. 
42 


g^g  DISEASES  OF  CHILDBED. 

layer  of  the  broad  ligament,  the  glue  spread  between  the  folds  to  the 
abdominal  end  of  the  Fallopian  tube ;  thence,  following  the  track  of 
the  vessels,  it  passed  to  the  linea  terminalis ;  and  finally  mounted  up- 
ward along  the  colon  or  swept  forward  to  Poupart's  ligament,  until  the 
advance  wjis  stopped  at  the  outer  border  of  the  rotind  ligament.  If 
the  injection  was  made  to  the  side  of  the  cervix  through  the  posterior 
layer  at  the  junction  of  the  cervix  and  the  body,  the  posterior  layer 
gradually  bulged  out,  the  peritonaeum  was  lifted  from  the  side  wall  of 
the  pelvis,  and  the  glue  passed  beyond  the  vessels  to  reach  the  iliac 
fossa.  If  the  injection  was  made  to  the  side  of  the  cervix  through  the 
anterior  layer,  the  glue  passed  between  the  bladder  and  the  uterus, 
and  forward  along  the  round  ligament  to  the  inguinal  canal,  while 
another  portion  of  the  fluid  passed  between  the  layers  of  the  broad 
ligament,  and  reached  the  peritoneal  covering  of  the  side  walls  behind 
the  round  ligament.  If  the  injection  was  made  in  the  m^edian  line,  in 
a  peritoneal  fold  of  Douglas's  cul-de-sac,  the  fluid  traveled  forward 
upon  one  side  along  the  round  ligament,  and  thence  to  the  posterior 
wall  of  the  bladder. 

The  term  parametritis,  introduced  into  use  by  Virchow,  is,  proper- 
ly speaking,  limited  to  inflammation  of  the  connective  tissue  imme- 
diately adjacent  to  the  uterus,  the  older  one  of  pelvic  cellulitis  furnish- 
ing a  more  comprehensive  designation  for  cases  where,  as  a  consequence 
of  a  progressive  advance  from  the  point  of  departure  in  the  genital 
canal,  the  remoter  regions  have  likewise  been  invaded.  Connective- 
tissue  inflammation  presents,  as  the  first  essential  characteristic,  an  acute 
cedema,  the  fluid  which  fills  the  gaps  and  interspaces  consisting  of 
transuded  serum  rendered  opaque  by  the  presence  of  pus-cells  or  pos- 
sessing a  gelatinous  character.  In  the  mild,  uncomplicated  cases,  the 
oedema  disappears  rapidly.  Where  the  cell-collections  are  of  mod- 
erate extent,  the  entire  process  may  vanish  without  leaving  a  trace  of 
its  existence.  If  the  cell-elements,  on  the  other  hand,  are  present  in 
great  abuadance,  they,  as  a  rule,  first  undergo  fatty  degeneration,  and, 
after  the  absorption  of  the  fluid  portion,  form  a  hard  tumor  composed 
of  a  fine  granular  detritus,  which  under  favorable  circumstances  like- 
wise, after  a  few  weeks,  becomes  absorbed.  In  rare  cases,  abscess-for- 
mation in  the  tumor  results. 

In  the  cellulitis  resulting  from  the  more  intense  forms  of  septic 
infection,  and  especially  when  complicated  by  diphtheritis,  the  tissues 
seem  as  if  soaked  with  dirty  serum,  and  contain  scattered  yellowish 
deposits,  which  soon  present,  even  to  the  naked  eye,  the  appearance  of 
pus-collections.  This  sero-purulent  cedema  is  always  associated  with 
lymphangitis,  the  lymphatic  vessels  possessing  varicose  dilatations  and 
beaded  arrangements  similar  to  those  already  described  in  the  uterine 
tissue.  The  foregoing  changes  are  most  distinct  in  the  firm  connective 
tissue  adjacent  to  the  uterus  and  at  the  hilum  of  the  ovary,  while  they 


PUERPERAL  FEVER.  659 

are  less  clearly  traced  in  the  loosor  structure  of  the  broad  ligament 
(Spiegelberg). 

In  favorable  cases  the  infliimmation  is  circumscribed,  or  at  least  is 
limited,  by  the  nearest  lymphatic  glands.  In  cases  of  more  severe  in- 
fection it  spreads  rapidly,  and  justifies  the  title  bestowed  upon  it  by 
Virchow  of  parametritic  malignant  erysipelas. 

Pelvic  and  Diffused  Peritonitis. — Inflammation  of  the  pelvic  peri- 
toui^um  may  proceed  from  severe  attacks  of  catarrhal  endometritis,  the 
inflammatory  process  either  traversing  the  uterine  tissue  or  passing 
through  the  Fallopian  tubes  to  the  adjacent  serous  membrane  ;  in  cases 
of  cellulitis  it  may  follow  the  penetration  of  pus  corpuscles  and  coccus 
forms  through  the  lymphatic  intersjiaces  and  between  the  endothelia 
into  the  peritoneal  cavity. 

As  a  rule,  pelvic  peritonitis  is  not  attended  with  much  exudation. 
The  latter  is  situated  upon  the  folds  of  the  peritongeum  limiting  the 
cul-de-sac  of  Douglas,  upon  the  ovaries,  and  upon  the  broad  ligaments. 
In  favorable  cases  it  consists  of  fibrinous  flakes  and  fluid  pus.  If  the 
latter  is  abundant,  it  may  become  encysted  by  the  formation  of  adhe- 
sions between  the  pelvic  organs. 

General  peritonitis  may  result  from  the  extension  of  a  pelvic  perito- 
nitis, from  the  introduction  of  infectious  materials  into  the  abdominal 
cavity  as  a  consequence  of  rui)tures  of  the  uterus  or  vagina  or  of  per- 
foration of  walls  of  pus  collections,  whether  contained  in  the  tubes  or  in 
the  pelvic  cavity,  or  from  the  transport  of  poison  through  the  lym- 
phatics into  the  peritoneal  sac.  In  the  first  cases,  which  are  character- 
ized by  the  formation  of  pus  and  fibrin,  the  intestines  are  distended 
and  the  diaphragm  is  pushed  upward.  The  process  begins  with  capil- 
lary injection  of  the  peritonaeum,  with  exudation  upon  the  dejDcndent 
portions  of  the  abdominal  space,  and  with  the  appearance  of  leucocytes 
about  the  vessels  and  in  the  exudate.  This  is  followed  by  fibrinous  exu- 
dation upon  the  intestines,  which  unites  them  loosely  together.  The 
endothelial  cells  of  the  abdominal  sac  swell  and  their  nuclei  multiply ; 
later,  the  exudate  increases  and  becomes  purulent  or  watery,  but  is  al- 
ways mixed  with  fibrin.  The  enlarged  endothelial  cells  strip  off,  the 
peritoneal  and  intestinal  walls  swell  and  are  infiltrated  with  leucocytes 
and  cells  from  the  division  of  the  connective-tissue  corpuscles.  By  a 
continuance  of  this  process  granulation  tissue  is  produced,  which  unites 
adjacent  tissues.  The  watery  constituents  of  the  exudation  are  then 
absorbed,  or  pus  collections  persist,  surrounded  by  pyogenic  membranes. 

These  encysted  collections  may  undergo  caseous  changes  or  become 
ichorous,  or  may  perforate  into  an  intestine,  the  bladder,  the  vagina,  or 
through  the  navel. 

In  the  so-called  peritonitis  lymphatica  the  inflammatory  symptoms 
are  at  the  outset  lacking.  The  abdominal  cavity  is  found  filled  with  a  thin, 
stinking,  greenish  or  brownish  fluid  composed  of  serum  and  micrococci. 


g^Q  DISEASES  OF  CHILDBED. 

The  intestines  are  lax  and  cedematous,  and  tlie  muscular  structures  are 
paralyzed,  with  the  resulting  tympanitic  distention.  The  peritoneal 
covering  of  the  intestines  is  devoid  of  luster  and  covered  with  injected 
patchest  or  is  stained  of  a  dark-brown  color.  Death  often  ensues  be- 
fore the  occurrence  of  exudation. 

Septic  forms  of  pelvic  inflammation  are  often  associated  with 
oophoritis,  the  dilated  lymphatics  either  extending  to  the  substance  of 
tlie  ovaries,  where  they  may  lead  to  the  production  of  small  abscesses, 
or,  as  a  result  of  blood  dissolution,  the  organs  become  soft,  pulpy,  and 
infiltrated  with  discolored  serum,  and  present  haemorrhagic  spots  dis- 
tributed over  the  surface. 

Phlebitis  and  Phlebo-thrombosis.— The  formation  of  throml)i  in  the 
uterine  and  pelvic  veins  is  sufficiently  common  during  the  puerperal 
period.  The  coagulation  may  result  from  compression  or  from  enfee- 
blement  of  the  circulation.  A  predisposition  to  its  occurrence  is  created 
by  relaxation  of  the  uterine  tissue.  A  normal  thrombus  is  in  itself 
harmless.  In  time  it  becomes  organized,  and  the  occluded  vessel  is 
converted  into  a  connective-tissue  cord,  or  a  channel  may  form  through 
it  which  permits  the  passage  of  the  blood-stream.  When,  however, 
septic  microbes  obtain  access  to  a  thrombus,  it  undergoes  rapid  disin- 
tegration, and  the  particles  get  swept  away  into  the  circulation  until 
arrested  in  the  ramifications  of  the  pulmonary  artery.  Wherever  these 
poisoned  emboli  happen  to  lodge,  inflammation  is  set  up  in  the  adjacent 
tissues,  and  abcesses  result  (pya?mia  nniltiplex).  Sometimes  countless 
collections  of  pus  may  form  in  the  lungs.  Less  commofily  abscesses  are 
found  in  the  liver  or  spleen,  originating  either  from  emboli  which  have 
already  made  the  pulmonary  circuit,  or  from  thrombi  in  the  i)ulmonary 
veins. 

Inflammation  of  the  veins  (phlebitis)  sometimes  occurs  when  the  ves- 
sels have  to  traverse  tissues  in  or  near  the  uterus  infiltrated  with  puru- 
lent or  septic  materials.  The  endothelium  then  undergoes  prolifera- 
tion, and  thrombosis  is  produced.  Phlebitic  thrombi  do  not  necessarily 
break  down,  and  may  in  that  case  act  as  a  barrier  to  the  progression  of 
septic  germs  into  the  circulation  (Spiegelberg).  As  a  rule,  however, 
under  the  influence  of  inflammation  and  infection,  they  become  con- 
verted into  puriform  masses. 

The  thrombi  grow  by  accretion  in  the  direction  of  the  heart.  They 
may  extend  from  the  uterus  through  the  internal  spermatic,  or  through 
the  hypogastric  and  common  iliac  veins,  to  the  vena  cava.  Sometimes 
the  thrombus  may  be  traced  back  to  the  placental  site. 

Septicaemia. — From  these  local  conditions,  sooner  or  later,  secondary 
affections  develop  in  distant  organs.  The  general  affection  is,  in  great 
part  at  least,  likewise  of  local  origin.  Sometimes,  however,  where  the 
poison,  which  enters  tlie  system  through  the  lymphatics  and  veins,  is 
very  active  and  abundant,  death  may  follow  from  acute  septicaemia 


PUERPERAL   FEVER.  661 

before  the  changes  in  the  sexual  organs  have  had  time  to  develop. 
The  fatal  result,  in  these  cases,  is  probably  due  to  paralysis  of  the  heart. 
After  death,  jmst-moi'tem  decomposition  rapidly  sets  in,  the  blood  is 
sticky,  and  swelling  is  found  in  the  various  parenchymatous  organs. 

The  secondary  affections  consist  in  the  metastatic  abscesses  already 
noticed  as  produced  by  infected  emboli,  in  circumscribed  purulent 
collections  due  to  the  conveyance  of  septic  materials  into  the  blood- 
current  through  the  lymphatics,  in  ulcerative  endocarditis,  in  inflam- 
mations of  the  pleura,  the  pericardium,  and  the  meninges,  and  in 
purulent  inflammation  of  the  Joints. 

Saprsemia  (Putrid  intoxication). — This  term  was  invented  by 
Matthews  Duncan  to  apply  to  the  fever  which  results  from  the  absorp- 
tion into  the  blood  of  sepsin  and  the  ptomaines,  the  products  of  putre- 
faction, in  distinction  from  the  febrile  forms  due  to  the  entry  into  the 
circulation  of  bacteria  capable  of  reproduction.  In  saprsemia  the  fever 
and  general  symptoms  rapidly  disappear  when  the  source  of  poison 
supply,  usually  the  uterine  cavity,  has  been  washed  clean  and  thoroughly 
disinfected. 

A  study  of  the  nature  of  puerperal  fever  will  best  show  how  inti- 
mately these  seemingly  distinct  processes  are  linked  together. 

Earlier  Views  concerning-  the  Nature  of  Puerperal  Fever.* — Ac- 
cording to  the  teachings  of  Hippocrates,  Galen,  and  Avicenna,  of 
Ambrose  Pare,  of  Sydenham,  and  of  Smellie,  the  fevers  of  puerperal 
women  were  attributable  to  the  suppression  of  the  lochia.  For  twenty 
centuries  this  doctrine  was  accepted  almost  without  dispute,  the  best 
clinical  observers  confounding  a  symptom  which  is  often  lacking  with 
the  cause  of  the  disease  itself. 

In  1686,  Puzos  f  taught  that  milk,  circulating  in  the  blood,  is  at- 
tracted to  the  uterus  during  pregnancy  and  to  the  breasts  after  con- 
finement, but  tliat  milk  metastases  may  form  in  other  parts,  and 
produce  the  symptoms  of  malignant  or  intermittent  fever.  In  1746 
A.  de  Jussieu,  Col  de  Villars,  and  Fontaine  advanced  in  support  of 
this  theory  the  fact  that  they  had  found,  on  opening  the  abdomen  in 
women  who  had  died  from  an  epidemic  which  raged  that  year  in 
Paris,  a  free  lactescent  fluid  in  the  lower  portion  of  the  abdominal 
cavity  and  clotted  milk  adherent  to  the  intestines.  This  doctrine, 
which  seemed  to  be  based  upon,  and  to  accord  with  observation,  found 
many  adherents  in  France.  It  lost  ground,  however,  when,  in  1801, 
Bichat  pointed  out  the  true  nature  of  the  abdominal  effusions  of  women 
who  had  died  in  childbed,  and  demonstrated  that  they  were  to  be  found 
likewise  in  peritoneal  inflammations  occurring  in  men  and  in  non- 
puerperal women. 

*  For  data  given,  and  for  a  great  variety  of  historical  information,  vide  Her- 
viEux,  Traite  clinique  et  pratique  des  maladies  puerperales. 
f  Premier  memoire  sur  les  depots  lacteux. 


QQ,2  DISEASES  OF  CHILDBED. 

While,  during  the  second  half  of  the  eighteenth  century,  the  doc- 
trine of  milk  metastasis  held  full  sway  in  France,  in  England  and 
Germany  the  dominant  leaders  in  medicine  referred  the  causes  of 
puerperal  fevers  to  inflammations  of  the  womb  and  of  the  pei'itonaium. 
With  the  advances  made  in  pathological  anatomy  in  the  beginning  of 
the  present  century,  France  taking  the  lead,  stress  was  likewise  laid 
upon  inflammations  of  the  veins  and  of  the  lymphatics.  The  vitality 
of  the  doctrine  of  local  inflammations  is  well  shown  by  the  records 
kept  by  the  Health  Board  of  this  city,  where  a  large  proi)ortion  of 
the  deaths  returned  from  childbed  fever  are  entered  under  the  head 
of  metritis,  of  peritonitis,  of  metro-peritonitis,  and  of  puerperal  phle- 
bitis. 

In  opposition  to  the  doctrines  of  the  so-called  localists,  the  theory 
that  puerperal  fever  is  an  essential  fever,  and  as  much  a  distinct  dis- 
ease as  typhus  fever,  typhoid  fever,  or  relapsing  fever,  has  been  strenu- 
ously advocated  by  some  of  the  most  distinguished  clinical  teachers 
who  have  devoted  their  attention  to  obstetrical  science. 

Fordyce  Barker,  in  his  classical  work  upon  the  Puerperal  Diseases, 
states  the  arguments  against  the  local  origin  of  tlie  diseases  as  follows : 
1st,  that  puerperal  fever  has  no  characteristic  lesions ;  2d,  that  the 
lesions  which  do  exist  are  often  not  sufficient  to  influence  the  progress 
of  the  disease  or  to  explain  the  cause  of  death  ;  3d,  that  there  may  be 
inflammation,  even  to  an  intense  degree,  of  any  of  the  organs  in  which 
the  principal  lesions  of  puerperal  fever  are  found,  and  yet  the  disease 
will  lack  some  of  the  essential  characteristics  of  puerperal  fever ;  4th, 
that  the  lesions  are  essentially  different  from  spontaneous  or  idiopathic 
inflammations  of  the  tissues  where  these  lesions  are  found ;  5th,  that 
puerperal  fever  is  often  communicable  from  one  patient  to  another 
through  the  medium  of  a  third  party,  and  that  this  is  not  the  fact  in 
regard  to  simple  inflammations  in  puerperal  women. 

However,  neither  Barker  nor  those  who  entertain  views  similar  to 
his  question  the  local  origin  of  many  febrile  affections  in  childbed,  but 
claim  that  purely  local  inflammations  have  each  their  characteristic 
symptoms,  which  differ  from  those  of  true  puerperal  fever  ;  tliat  puer- 
peral fever  is  a  zymotic  disease  of  unknown  origin ;  and  that  local 
lesions,  where  they  coexist,  are  not  the  primary  source  of  trouble,  but 
are  secondary  to  changes  in  the  blood. 

In  1850  James  Y.  Simpson*  published  a  short  paper  On  the 
Analogy  between  Puerperal  and  Surgical  Fever.  This  article  may  well 
be  regarded  as  the  foundation  of  the  modern  doctrine  concerning  puer- 
peral fever,  and  is  well  worthy  of  perusal  at  the  present  day;  for, 
though  in  the  then  existing  state  of  pathology  many  of  the  links  were 
wanting  which  have  since  raised  the  argument  to  nearly  a  mathemati- 
cal demonstration,  the  paper  furnishes  a  brilliant  example  of  the 
*  Edinburgh  Medical  Journal. 


PUERPERAL   FEVER.  663 

scientific  foresight  wliicli  is  able  to  discern  the  truth  even  where  tlie 
evidence  lacks  completeness. 

In  1847  Semmelweis,  who  was  at  that  time  clinical  assistant  to  the 
Lying-in  Hospital  at  Vienna,  made  the  startling  assertion  that  "  puer- 
peral patients  were  chiefly  attacked  with  puerperal  fever  when  they  had 
been  examined  by  the  physicians  who  were  fresh  from  contact  with 
the  poisons  engendered  by  cadaveric  decay ;  that  fever  ensued  in  the 
practice  of  those  who,  after  post-mortem  examination,  washed  their 
hands  in  the  usual  manner,  whereas  no  fever  or  but  few  cases  of  disease 
followed  when  the  examiner  had  previously  washed  his  hands  in  a  solu- 
tion of  chloride  of  lime."  In  the  face  of  insult,  ridicule,  and  abuse  Sem- 
melweis maintained  this  position  for  years,  almost  unaided,  with  fanatical 
persistency.  It  was  easy  for  his  opponents,  for  the  most  part  man- 
agers of  the  great  lying-in  asylums,  to  show  from  clinical  experiences 
the  weakness  of  so  one-sided  a  theory.  But  the  employment  of  the 
equivocal  demonstration /r/Z^-Ms  in  nno,faIsus  in  omnihns,  served  only 
as  a  temporary  defense  against  the  laxity  which  prevailed  in  hospital 
management  only  a  quarter  of  a  century  ago.  Though  Semmelweis 
died  with  no  other  reward  than  the  scorn  of  his  contemporaries,  it  is 
impossible  at  the  present  day  to  so  much  as  contemplate  the  abuses  he 
attacked  without  a  shudder. 

In  1800  Semmelweis  published  the  result  of  his  ripened  experience 
in  a  treatise  entitled  Die  Aetiologie,  der  Begriff  und  die  Prophylaxis 
des  Kindbett-fiebers,  in  which,  abandoning  his  earlier  exclusive  posi- 
tion, he  maintained  that  puerperal  fever  arises  from  the  absorption  of 
putrid  animal  substances,  which  produce  first  alterations  in  the  blood, 
and  secondly  exudations.  He  distinguished  between  cases  in  which 
the  infection  was  introduced  from  some  external  source,  and  which  he 
believed  to  be  the  most  frequent  variety,  and  those  where  the  poison 
was  generated  in  the  system.  The  sources  from  which  the  infection 
is  derived  he  believed  to  be — 1st,  from  the  dead  body,  regardless  of  age, 
sex,  or  disease,  no  matter  whether  the  latter  is  of  puerperal  or  non- 
puerperal origin,  the  virulence  depending  upon  the  stage  of  decom- 
position ;  2d,  diseased  persons,  whose  malady  is  associated  with  decom- 
position of  animal  tissue,  no  matter  whether  the  affected  person  suf- 
fers from  childbed  fever  or  not,  the  decomposing  matter  alone  furnish- 
ing the  product  from  which  infection  is  derived ;  3d,  physiological 
animal  substances  in  the  process  of  decomposition.  As  carriers  of 
infection,  he  regarded  the  fingers  and  hands  of  the  physician,  midwife, 
or  nurse,  sponges,  instruments,  soiled  clothing,  the  atmosphere,  and,  in 
brief,  anything  which,  after  being  defiled  with  decomposing  animal 
matter,  was  brought  into  contact  with  the  genitals  of  a  woman  during 
or  subsequent  to  parturition.  Absorption  takes  place  from  the  inner 
surface  of  the  uterus  or  from  traumata  in  the  genital  canal.  Infection 
seldom  occurs  in  pregnancy,  because  of  the  closure  of  the  os  internum, 


QQ^  DISEASES  OF  CHILDBED. 

the  absence  of  wounded  surfaces,  and  because  of  the  rarity  with  which 
examinations  are  made;  during  dilatation  infection  is  common,  but 
exceptional  during  the  period  of  expulsion,  because  the  inner  uterine 
surface  is  at  that  time  rendered  inaccessible  by  the  advance  of  the 
child;  in  the  placental  and  puerperal  period  infection  occurs  from 
utensils  and  instruments,  but  chiefly  through  the  access  of  atmospheric 
air  when  the  latter  is  loaded  with  decomposing  organic  matter.  In 
rare  instances,  auto-infection  may  result  from  spontaneous  decomposi- 
tion of  the  lochia,  of  bits  of  decidua,  of  coagula  of  blood,  of  necrosed 
tissue,  or  in  consequence  of  severe  instrumental  labors.  In  a  v/ord, 
puerperal  fever  was,  according  to  Semmelweis,  no  new  specific  disease, 
but  a  variety  of  pyemia. 

The  Nature  of  Puerperal  Fever  as  regarded  from  the  Standpoint  of 
Modern  Investigation. — The  older  beliefs  in  the  suppression  of  the 
lochia  and  the  metastases  of  milk  have  long  since  been  relegated  to  the 
domain  of  old  nurses'  lore,  and  do  not  call  for  serious  discussion.  The 
localist  theory,  that  puerperal  fever  is  a  metritis,  a  peritonitis,  a  phle- 
bitis, or  an  inflammation  of  the  lymphatics,  is,  as  mortuary  records 
show,  still  adhered  to  by  many  practitioners,  and,  as  we  have  seen,  is 
Justified  by  the  fact  that  puerperal  fever  is,  with  rare  exceptions,  asso- 
ciated, at  some  period  of  its  progress,  with  certain  inflammatory  pro- 
cesses which  have  their  starting-point  in  the  generative  apparatus. 
But  the  localist  theory  leaves  out  of  view  the  existence  of  blood-poison- 
ing, and  yet  the  coexistence  of  a  blood-poison  with  the  local  lesions  is 
an  essential  feature  of  puerperal  fever.  It  was  this  defect  which  gave 
to  tlie  advocates  of  the  specificity  of  puerperal  fever  their  real  impor- 
tance. Modern  investigation  has,  however,  proved  that  the  puerperal 
poison  is  septic  in  character,  and  that  puerperal  fever  is  really  a  surgical 
fever,  modified,  however,  by  the  peculiar  physiological  conditions 
which  belong  to  the  puerperal  state. 

Thus,  it  has  been  found  that,  in  the  human  subject,  and  in  expari- 
ments  made  upon  animals,  septic  poisons  introduced  into  the  system 
following  or  near  delivery  produce  lesions  similar  to  those  found  in 
puerperal  fever.  As  a  further  coincidence,  it  has  been  noticed  that, 
as  in  puerperal  fever,  the  lesions  from  direct  septic  poisoning  have 
nothing  characteristic  about  them,  producing  in  one  case  pyaemia,  in 
another  partial  peritonitis,  in  another  general  peritonitis,  in  another 
diphtheritis,  while  in  others  the  lesions  are  comparatively  trivial,  these 
differences  being  due  to  variable  facta,  such  as  the  qualities  of  the 
septic  poisons,  the  points  of  entry  into  the  organism,  and  the  resistance 
offered  by  the  invaded  tissues. 

There  is  one  experimental  point  of  extreme  practical  importance  in 
connection  with  puerperal  septicaemia— viz.,  that  if  the  injection  of  a 
septic  fluid  be  made  directly  into  a  vessel,  toxic  effects  speedily  follow, 
but  are  transitory,  unless  the  amount  of  the  fluid  be  large,  or  its  viru- 


PUERPERAL  FEVER. 


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Q^Q  DISEASES   OF   CHILDBED. 

lence  exceptional,  or  the  animal  veiy  young;  whereas  very  small 
amounts  injected  subcutaneously,  by  developing  rapidly  spreading 
phlegmonous  inflammation,  resembling  malignant  erysipelas  in  man, 
are  capable,  after  a  period  of  incubation,  of  producing  fatal  results ;  or 
they  may,  if  injected  into  a  shut  cavity  or  underneath  a  fascia,  lead  to 
the  development  of  an  inflammation  of  an  ichorous  character.  In  other 
words,  the  eliminating  organs  sufUce,  under  ordinary  conditions  to  re- 
move from  the  blood  an  amount  of  septic  fluid  which  would  prove  fatal 
if  injected  into  the  tissues.  To  produce  similar  results  the  injections 
into  the  blood  need  to  be  repeated  at  intervals.  This  experience  leads 
us  to  the  conclusion  that,  in  the  tissues,  septic  poisons  possess  the 
capacity  of  self-multiplication,  and  that  from  the  local  inflammation 
set  up  a  supply  is  formed  from  which  poisonous  matter  is  continuously 
poured  into  the  circulation. 

The  capacity  of  self-multiplication  with  which  septic  materials  are 
endowed  has  been  found  to  be  the  property  of  certain  parasitic  bodies 
termed  bacteria.  The  prevailing  pathogenic  organisms  in  puerperal- 
fever  cases,  according  to  the  researches  of  Doleris,  consist  of  bacilli  or 
rods,  and  of  micrococci  in  the  varieties  of  monococci  or  single  points; 
of  diplococci,  double  points;  and  of  streptococci  or  chain  and  wreaths. 
Staphylococci  are  sometimes  found  in  parametritic  abscesses,  or  even  in 
the  uterine  cavity.  It  is  conceded,  however,  that  the  stre2)tococci  are 
the  important  factors  in  the  production  of  infection. 

Without  entering  upon  diflficult  and  unsettled  questions  concerning 
the  manner  in  which  disease  germs  accomplish  their  destructive  work 
during  the  puerperal  period,  it  may  be  stated  that,  in  the  first  place, 
they  generate,  as  one  of  their  vital  functions,  toxic  substances  which 
kill  the  tissues,  excite  inflammations,  produce  fever,  and  give  rise  to 
nervous  disorders. 

The  bacilli  are  the  agents  of  putrefaction.  Their  action  is  local. 
They  attack  dead  tissue  only  (clots,  bits  of  placenta,  shreds  of  mem- 
brane, portions  of  decidua).  They  do  not  themselves  invade  the  tis- 
sues. The  products  of  putrefaction  contain  certain  poisons  termed 
ptomaines,  which  when  they  enter  the  circulation,  cause  a  general  in- 
toxication. AVhen  the  offending  substances  are  removed  from  the 
uterine  cavity,  the  systemic  symptoms  disappear. 

The  instinct  which  prompts  the  employment  of  the  disinfectant 
douche  in  cases  where  there  is  a  stinking  lochial  discharge  is  a  sound 
one,  but  it  is  a  common  clinical  observation  that  in  many  cases  the 
symptoms  continue  thereafter  unabated,  and  that,  likewise,  in  severe 
and  even  in  fatal  forms  of  puerperal  fever  the  lochia  are  free  from 
odor. 

True  infective  puerperal  fever  has  no  direct  connection  with  putre- 
factive organisms.  It  is  the  product  of  the  streptococci,  which  not 
only  are  in  themselves  highly  poisonous,  but  possess  the  faculty  of 


PlaU  IK 


Microscopic  Sections  in  Puerperal  Endometritis.    (Bumm.) 
F{g   1. 


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PUERPERAL  FEVER.  667 

invading  living  tissue.  But  the  putrefactive  and  the  infective  germs 
are  generally  present  together.  It  is  surmised  that  when  they  are  thus 
associated,  the  putrid  endometritis  excited  by  the  one  furnishes  a  con- 
genial soil  which  favors  the  multiplication  of  the  other. 

DESCRIPTION    OF   PLATE   IV. 
Microscopic  Sections  in  Puerperal  Endometritis.    (Bcmm.) 

Fig.  1. — Section  through  decidiia  removed  by  curette  in  case  of  putrid  endo- 
metritis (ninth  day  of  childbed),  a,  necrosed  layer  of  decidua  infiltrated  with  putre- 
factive germs ;  b,  reaction  layer,  showing  nuclei  of  the  leucocytes. 

Fig.  2. — Section  through  decidua  in  case,  of  septic  endometritis  (seventh  day 
of  childbed).  Plate  cultures  furnished  streptococci  pyogenes,  staphylococci  aurei, 
and  several  saphrophytes.  a,  necrosed  layer  of  decidua ;  b,  reaction  zone  ;  c,  gland 
lumina;  d,  section  through  vessels:  e,  remains  of  glandular  epithelium. 

Fig.  3a. — Section  through  decidua  and  adjacent  muscular  walls  from  a  puer- 
peral woman  who  died  of  acute  sepsis,  with  septic  peritonitis,  on  the  fourth  day  of 
childbed,     a,  necrotic  decidua ;  b,  muscular  tissue. 

Fig.  3b. — Portion  of  Fig.  3a  more  highly  magnified.  Streptococci  growing  be- 
tween the  muscular  fibers,  as  in  erysipelas. 

Fig.  5. — Section  of  uterine  wall  in  lymphatic  peritonitis  (death  on  twelfth  day). 
a.  lymph  vessel  filled  with  streptococci;  b,  eruption  of  the  fungi  into  the  adjacent 
muscular  tissue,  which  has  become  necrosed.     Arborescent  distribution. 

Earely  the  streptococci  pass  from  the  uterine  cavity  by  the  Fallo- 
pian tubes  to  the  periton.eal  sac.  This  probably  only  happens  when 
the  tubes  have  been  rendered  patent  by  antecedent  disease.  In  many 
instances  the  action  of  the  streptococci  is  confined  to  the  inner  surface 
of  the  uterus.  In  these  cases  and  in  those  of  ordinary  putrid  endome- 
tritis a  layer  of  leucocytes  forms  next  to  the  necrosed  tissues  which 
acts  as  a  w^all  to  prevent  the  penetration  of  the  germs  into  deeper-lying 
structures.  In  the  event  of  general  infection,  this  barrier  has  been 
feebly  developed,  and  was  easily  broken  through  by  the  invading  host. 

In  the  lymjihatic  form  of  septicaemia  tlie  streptococci  pass,  sometimes, 
through  the  narrow  gaps  between  the  muscular  fibers  to  the  peritoneal 
surface  of  the  uterus,  or,  more  frequently,  they  enter  the  canalicular 
spaces  in  the  connective  tissue  forming  the  framework  of  the  genital 
canal  which  is  continuous  with  subperitoneal  connective  tissue  of  the 
pelvis.  From  the  canalicular  spaces  they  enter  the  lymphatics.  Cel- 
lulitis is  excited  by  their  presence,  and  the  lymphatic  glands  become 
inflamed  and  enlarged.  In  the  walls  of  the  uterus  the  lymphatics 
are,  in  places,  found  distended  with  cocci,  which  excite  inflammatory 
processes  in  the  neighborhood  followed  by  necrosis  of  the  muscular 
structures,  by  migration  into  the  softened  tissue  of  masses  of  leucocytes, 
and  by  the  formation  of  small  sequestered  abscesses  (Bunim).* 

In  pernicious  forms  they  produce  a  sero-purulent  oedema,  which 
spreads  rapidly  with  a  wave-like  progress  after  the  manner  of  erysipe- 
las ;  or,  in  milder  cases,  the  progress  of  the  disease  germs  is  arrested  by 

*  BuMM,  Histologische  Untersuchungen  ueber  die  puerperale  Endometritis.  Arch, 
f.  Gynaek.  Bd.  xl,  pp.  398  et.  seq. 


gg3  DISEASES  OP  CHILDBED. 

the  lymphatic  ghiuds  or  the  resistance  offered  by  the  tissues  themselves, 
and  the  ordinary  circumscribed  phlegmon  is  produced.  By  the  lym- 
phatics which  accompany  the  vessels  of  the  Fallopian  tubes  they  reach 
the  ovaries  (puerperal  ovaritis),  and  by  the  broad  ligaments  they  pass  to 
subperitoneal  tissues  of  the  iliac  and  lumbar  regions.  Through  the  same 
system  they  are  conveyed  to  the  great  serous  cavities  of  the  body.  In 
the  peritontfium  they  give  rise,  unless  death  occurs  too  speedily,  to 
pya3mic  peritonitis,  which,  unlike  the  traumatic  form,  is  attended  with 
but  little  pain.  The  wide  stomata  upon  the  abdominal  surface  of  the 
diaphragm  allow  the  facile  entrance  of  the  organisms  into  its  lym- 
phatics. Waldeyer  found,  in  diaphragmitis,  the  lymphatics  of  the  dia- 
phragm filled  with  bacteria.  And  thus,  following  the  lymphatic  sys- 
tem, the  frequency,  in  severe  types  of  puerperal  fever,  of  inflammation 
of  the  serous  membranes  of  the  peritoufeum,  the  plural,  the  pericardi- 
um, the  meninges,  and  the  Joints  finds  an  easy  explanation.  Nor  is  it 
altogether  accident  which  determines  in  different  cases  the  precise  serous 
membranes  which  are  affected.  The  widespread  ramifications  of  the 
lymphatic  system  would  naturally  give  rise  to  eccentric  inflammations 
in  place  of  those  following  the  apparent  continuity  of  tissues. 

When  the  streptococci  infect  wounds  about  the  vulva  and  in  the  va- 
gina the  resulting  process  is  apt  to  be  local  unless  the  germs  possess  an 
unusual  degree  of  virulence.  As  regards  their  effect  upon  wounds  of 
the  cervix,  the  question  is  still  open  to  debate,  but  here,  too,  it  is  prob- 
able that  the  tendency  is  to  the  formation  of  circumscribed  inflamma- 
tions. 

The  streptococci  are  detected  with  difficulty  in  the  blood  during  life. 
A  few  hours  after  death  they  swarm  in  that  fluid.  That  they  do,  how- 
ever, enter  the  general  circulation  during  life  is  incontestable.  Steurer 
writes :  "  As  the  kidneys  are  the  great  filters  of  the  human  system,  I 
never  neglected  to  examine  them,  and  almost  invariably  found  micro- 
cocci filling  the  arterioles  and  glomeruli."  This  is  in  correspondence 
with  what  occurs  in  other  septic  diseases,  and  accounts  for  the  albumi- 
nuria and  interstitial  nephritis  which  often  supervene  in  the  advanced 
stages.  They  are  likewise  found  in  the  liver  and  in  the  spleen.  Doleris 
assures  us  that  in  puerperal  fever,  by  repeated  trial,  especially  after  a 
chill,  he  has  never  failed  to  demonstrate  their  presence  in  the  circula- 
tion. They  do  not,  however,  multiply  in  the  blood  during  life.  AVhen 
they  come  in  contact  with  the  red  corpuscles,  the  corpuscles  stick  to- 
gether and  form  larger  or  smaller  clots  in  the  blood.  They  then  are  no 
longer  able  to  pass  through  the  minute  capillary  networks,  but  are 
arrested  in  the  vessels  (Koch).  The  micrococci  in  the  resulting  infarc- 
tions multiply  and  migrate  into  the  vessels  and  cellular  tissue  of  the 
neighborhood.  Thus  fresh  foci  of  infection  are  formed.  Or,  by  their 
destructive  action  they  may,  when  situated  near  the  serous  surfaces, 
penetrate  into  the  serous  cavities,  and  in  this  way  indirectly  occasion 


PUERPERAL  FEVER,  669 

peritonitis,  pleurisy,  memngitis,  and  purulent  inflammations  of  the 
joints.  When  the  micrococci  enter  directly  into  the  circulation  they 
sometimes,  in  passing  through  the  heart,  adhere  to  the  endocardium 
and  the  valves,  where  they  cause  exudation  and  ulceration,  and  give  rise 
to  the  so-called  endocarditis  ulcerosa  puerperalis.  The  red  globules  of 
the  blood  undergo  changes  of  shape,  assume  a  stellate  aspect,  and  rap- 
idly disappear.  The  white  globules  are  greatly  increased  in  numbers, 
and  the  blood  itself  becomes  nearly  colorless.  A  certain  amount  of 
light  is  thrown  upon  these  blood  changes  by  Doleris,  who  added  mi- 
crococci to  the  fresh  blood  of  a  frog  and  watched  the  ensuing  changes 
under  the  microscope.  The  micrococci  could  be  seen  in  the  act  of  pen- 
etrating the  red  globules,  which  thereupon  lost  their  color  and  became 
shrunken,  and,  following  the  discharge  of  the  organisms,  which  mean- 
time had  multiplied  in  an  astonishing  manner,  little  or  nothing  of  the 
original  globules  remained. 

The  thrombotic  form  of  infection  has  been  studied  by  Bumm  in  the 
veins  which  spring  from  the  placental  site.  He  found  that  the  migra- 
tory movements  of  the  cocci  from  the  endometrium  followed  the  axis 
of  the  thrombus,  and  thence  spread  outward  toward  the  vein  walls.  The 
latter  then  became  infiltrated  with  round  cells,  which  quickly  made 
their  way  into  the  canal  of  the  vessel.  A  disintegration  of  the  clot  was 
associated  with  these  occurrences,  and  thus  the  vessel  became  filled  with 
a  detritus  composed  of  leucocytes,  of  parasitic  organisms,  and  of  the 
debris  of  the  thrombus.  In  other  instances,  according  to  Doleris,  micro- 
cocci derived  from  the  blood  are  deposited  upon  the  central  extremities 
of  the  clots ;  beyond  these  depots  a  fresh  inflammation  is  set  up,  fol- 
lowed by  fibrinous  coagulation.  Thus  the  micrococci  become  impris- 
oned between  two  plugs.  The  same  process  may  be  repeated  until  a 
series  of  abscesses  is  formed.  For  a  time  no  mischief  may  ensue- 
Finally,  however,  the  resistance  of  the  outworks  is  overcome,  an  embo- 
lus becomes  detached,  and  an  infectious  abscess  is  opened  into  the  blood 
— an  event  which  is  announced  by  an  intense  chill  and  the  familiar  sys- 
temic derangement. 

In  septic  diseases  death  takes  place  from  apncea,  partly  from  the 
inability  of  the  blood-corpuscles  to  carry  oxygen  to  the  tissues — and 
partly  from  paralysis  of  the  nerve  centers. 

In  estimating  the  susceptibility  to  sepsis  in  the  puerperal  state  it  is 
necessary  to  take  into  account  the  blood  changes  induced  by  pregnancy, 
the  effects  of  shock  and  exhaustion  in  protracted  labors,  the  frequency 
of  haemorrhage,  the  deep  situation  of  puerperal  wounds,  the  presence 
of  clots,  decidua,  and  dead  tissue  in  a  state  of  disintegration  or  decom- 
position, the  ease  with  which  deleterious  matters  are  absorbed  by  the 
wide  lymphatic  interspaces,  the  serous  infiltration  of  the  pelvic  tissues, 
the  exaggerated  size  of  the  lymphatics  and  veins,  and  the  proximity  of 
the  peritoneal  cavity. 


Q^Q  DISEASES  OF  CHILDBED. 

Samuel,*  in  speaking  of  the  immunities  and  dispositions  to  septic 
poisoning,  says :  "  The  statistical  frequency  of  septic  puerperal  dis3ase 
is  due  tothe  length  of  the  parturient  canal,  to  the  fact  that  through 
this  long  passage  there  must  pass  all  the  pathological  and  physiological 
excretions,  and  to  the  soiling  of  these  parts  with  fingers,  instruments, 
and  secretions  which  have  become  the  bearers  of  sepsis."  He  found, 
on  the  other  hand,  that  it  was  extremely  difficult  to  produce  a  progress- 
ive ichorous  condition  by  daily  painting  an  open  stump  with  a  septic 
fluid,t  though  the  same  was  readily  obtained  when  an  infinitesimal 
quantity  of  septic  fluid  was  injected  underneath  a  fascia. 

We  have  seen  that  when  septic  organisms  are  introduced  into  the 
uterine  cavity  there  are  individual  difi'erences  in  the  ensuing  results. 
Thus,  in  many  cases,  their  action  is  limited  to  the  production  of  local 
inflammatory  troubles  and  to  self -limited  systemic  disturbances,  while 
in  others  they  overcome  all  resistance  and  lead  to  the  most  far-reaching 
changes  in  the  blood,  in  the  circulatory  apparatus,  in  the  parenchyma- 
tous organs,  and  in  the  serous  cavities.  The  reason  for  these  differences 
are  to  a  certain  extent  a  matter  of  conjecture.  It  is,  however,  admitted 
that  the  virulence  of  disease  germs  may  be  modified  by  culture  experi- 
ments, or  by  seemingly  accidental  conditions.  Bumm  maintains  that 
what  is  termed  virulence  is  an  acquired  power  of  bacteria  to  withstand 
the  destructive  influences  upon  them  of  the  saps  and  tissues,  and  to 
multiply  within  the  living  body.  That  the  innate  powers  of  resistance 
to  morbific  agencies  differs  in  individuals  seems  probable.  Kehrer  re- 
minds us  that,  before  the  antiseptic  period,  it  was  not  uncommon  for  a 
practitioner  fresh  from  an  autopsy  upon  a  puerjieral  woman  who  had 
died  of  lymphatic  peritonitis,  to  examine  patients  in  labor  with  hands 
which  had  been  simply  washed  in  soap  and  water,  and  that  of  the 
women  thus  infected  a  certain  number  had  violent  or  even  fatal  forms 
of  sepsis,  while  others  were  scarcely  perceptibly  affected.  Doubtless, 
when  the  uterus  is  firmly  contracted,  the  clots  in  the  orifices  of  the 
placental  veins  are  small,  and  the  invasion  of  cocci  is  hindered  by  the 
compression  of  the  lymphatic  sj^aces,  and  vice  versa.  With  a  flabby,  re- 
laxed uterus,  the  soft  thrombi  and  the  widely  dilated  absorbents  furnish 
favorable  conditions  for  the  spreading  of  infection. 

While  insisting  upon  the  septic  character  of  puerperal  fever  and 
its  association  with  the  presence  of  streptococci,  it  is  not  pretended 
that  inflammations  of  the  pelvic  organs  in  childbed  may  not  proceed 
from  other  causes.  Indeed,  I  have  myself  witnessed  cases  where  peri- 
tonitis has  seemingly  started  from  old  intraperitoneal  adhesions,  or 
was  secondary  to  ulcerative  processes  in  the  caecum  or  the  descending 
colon.     I  am  inclined,  likewise,  to  agree  with   Genzmer  and  Volk- 

*Ueber  die  Wirkung  des  Fiiiilniss-Processes  auf  den  lebenden  Organisraus.  Arch, 
f.  exp.  Pjithologie.  vol.  i,  p.  343. 
t  Loc.  cit.,  p.  339. 


I 


PUERPERAL  FEVER.  671 

maun  *  tliat  there  is  such  a  thing  as  an  aseptic  surgical  fever  due  to  the 
absorption  of  the  products  of  physiological  tissue-changes  at  the  seat  of 
injury.  In  surgical  cases,  even  where  the  precautions  of  Listerism 
have  been  faultlessly  observed,  febrile  movements  of  considerable  in- 
tensity, but  of  no  prognostic  signification,  are  of  frequent  occurrence. 
AVhile,  in  puerperal  women,  we  can  never  exclude  the  possibility  of  the 
septic  infection  of  puerperal  wounds,  it  is  in  accordance  with  clinical 
experience  to  assume  that  a  higli  fever  belonging  to  the  aseptic  class 
may  coincide  with  a  septic  process  of  insignificant  proportions. 

General  Symptoms. — As  in  other  infectious  diseases,  there  is,  from 
the  time  of  the  entry  of  the  poison  into  the  system  up  to  the  outbreak 
of  fever,  a  distinct  period  of  incubation.  The  first  febrile  symjDtoms 
usually  occur  within  three  days  of  the  birth  of  the  child.  An  attack 
coming  on  a  few  hours  after  childbirth  is  indicative  of  infection  dur- 
ing or  previous  to  labor.  The  third  clay  is  the  one  upon  which,  ordi- 
narily, the  beginning  of  the  fever  is  to  be  anticipated.  After  the  fifth 
day  an  attack  is  rare,  and  at  the  end  of  a  week  patients  may  be  regarded 
as  having  reached  the  point  of  safety.  Apparent  exceptions  to  this 
rule  are  j^robably  referable  to  cases  of  mild  parametritis,  in  which  the 
initial  fever  and  the  pain  were  insufficient  to  attract  attention  to  the 
existence  of  local  inflammation. 

The  symptoms  of  puerperal  fever  vary  with  the  character  of  the 
local  afCections,  and  with  the  extent  to  which  the  general  system  par- 
ticipates in  the  disturbed  action.  The  different  groups  of  j^uerperal 
processes  possess  the  following  pathognomic  symptoms — viz.,  increased 
temperature,  enlargement  of  the  spleen,  disturbed  involution,  and 
sensitiveness  of  the  uterus  upon  pressure  (Braun). 

In  most  cases,  the  fever  is  ushered  in  by  chilly  sensations  or  by  a 
well-defined  chill.  This  symptom,  however,  does  not  possess  much 
prognostic  importance.  A  chill  is  significant  of  a  sudden  change  be- 
tween the  temperature  of  the  skin  and  that  of  the  surrounding  me- 
dium. It  may,  therefore,  be  absent  in  pernicious  forms  of  fever,  pro- 
vided only  that  the  temperature  changes  are  inaugurated  slowly, 
whereas  it  may  follow  a  trifling  increase  of  the  body  heat  if,  as  some- 
times happens  in  sleep,  the  moist  skin  is  exposed  to  cool  currents  of 
air.     Eepeated  chills  indicate  phlebitis  and  pyaemia. 

In  order  to  grasp  the  many  symptoms  of  puerjoeral  fever  it  is  neces- 
sary to  keep  separately  in  mind  the  clinical  features  of  each  of  the  local 
processes,  although  in  fact  the  latter  rarely  occur  singly,  but  to  a 
greater  or  less  extent  in  combination  with  others. 

The  Symptoms  of  Endometritis  and  Endocolpitis.— The  uncompli- 
cated catarrhal  inflammation  of  the  uterus  and  vagina  is  the  most  fre- 
quent and  the  mildest  of  the  diseases  of  childbed.     In  endometritis  the 

*  Genzmer  and  Volkmann,  Ueber  septisches  und  apeptisches  Wundfieber,  Samml. 
klin.  Vortriige,  No.  131. 


672 


DISEASES  OF   CQILDBED. 


uterus  is  large,  flabby,  and  sensitive  upon  pressure ;  the  after-pains  are 
often  unusually  severe,  involution  is  retarded,  and  the  lochia  become 
fetid,  remain  sanguinolent  for  a  longer  period  than  usual,  and  at  the 
outset  may  be  temporarily  suspended.  Sometimes  the  large  intestine 
is  distended  with  flatus.  In  endocolpitis  the  vaginal  discharge  is  thin 
and  purulent,  the  patient  experiences  pain  and  burning  in  the  acts  of 
defecation  and  urination,  and,  where  the  wounds  of  the  vulva  and 
vao-ina  assume  an  ulcerative  character,  there  is  often  found  at  the  same 
time  inflammatory  oedema  of  the  labia. 

The  fever  in  these  cases  is  ushered  in  frequently,  but  not  always, 
by  chilly  feelings,  and  the  tsmperature  reaches  its  height  usually  upon 
the  evening  of  the  third  or  fourth  day,  is  remittent,  almost  intermit- 
tent in  character,  and  rarely  exceeds  102°  to  103°  Fahr.  In  mild  forms 
the  occurrence  of  the  fever  is  often  overlooked,  or  is  referred  to  dis- 
turbance produced  by  the  secretion  of  the  milk.  In  severer  attacks 
the  febrile  symptoms  may  continue  from  three  to  seven  days.  At  the 
end  of  a  week  the  swelling  of  the  labia  subsides,  the  discharge  becomes 
thick,  and  ulcers,  if  present,  begin  to  assume  a  healthy  granulating 
appearance. 

In  diphtheritic  ulcerations,  and  in  endometritis  due  to  decompos- 
ing remains  of  the  ovum,  the  local  condition  is  often  complicated  by 
the  invasion  of  the  neighboring  tissues. 

The  Symptoms  of  Parametritis  and  Perimetritis  (Pelvic  perito- 
nitis *). — The  symptoms  of  these  two  alfeetious,  as  would  be  naturally 
expected  from  the  proximity  of  the  peritonaeum  to  the  pelvic  con- 
nective tissue,  for  the  most  part  overlap.  It  must  be  very  rare  for  one 
form  to  occur  entirely  independent  of  the  other.  For  this  reason  it 
will  be  found  convenient  to  consider  first  the  symptoms  common  to 
both  morbid  processes,  and  subsequently  to  direct  attention  to  what 
are  believed  to  be  points  of  distinction  between  them. 

During  the  period  of  incubation  there  are  usually  no  prodromic 
symptoms  Elevations  of  temperature  in  the  course  of  the  first  twelve 
hours  following  labor  are  equally  frequent  under  perfectly  normal  con- 
ditions. Suspicious  symptoms  are  disturbed  sleep,  excessively  painful 
after-pains,  and  a  pulse  of  80  to  90. 

The  beginning  of  the  fever  occurs,  in  90  per  cent,  within  the  first 
four  days  of  childbed  ;  most  frequently  upon  the  second  or  third  day, 
and  taking  place  upon  the  fourth  day  in  scarcely  12  to  15  per  cent  of 
the  cases.  If  five  days  have  elapsed  without  fever,  the  period  of  dan- 
ger, with  very  rare  exceptions,  may  be  regarded  as  having  passed. 

At  the  outset  the  fever,  especially  in  perimetritis,  is  ushered  in  by 

*  The  following  clinicjil  history,  together  with  the  statistical  details,  is  borrowed 
in  great  part  from  the  description  of  Olshaiisen  (Ueber  puerperale  Parametritis  und 
Perimetritis,  Volkmann's  Samml.  klin.  Vortr.,  No.  28),  the  exactitude  of  which  1 
have  had  abundant  opportunity  to  verify. 


PUERPERAL  FEVER.  673 

chilly  sensations  or  by  an  intense  chill.  The  temperature  rises  rap- 
idly, though  the  highest  point  is  usually  not  reached  before  the  sec- 
ond, and  in  rare  cases  not  before  the  third  day.  In  most  cases,  the 
heat  in  the  axilla  exceeds  103°,  and  may  even  mount  up  to  105°.  The 
decline  occurs  gradually,  the  fever  ending  in  70  per  cent  in  the  course 
of  a  week,  in  20  per  cent  in  two  weeks,  and  only  in  10  per  cent  ex- 
tending beyond  that  period.  Protracted  cases  indicate  abscess  formation. 

The  fever  does  not,  however,  always  pursue  a  regular  course.  In 
place  of  progressively  declining  until  the  termination  is  reached,  the 
high  temperature  of  the  second  day  may  be  attained  upon  one  or  more 
occasions.  The  morning  remissions  are  at  first  slight,  but  become 
marked  as  the  disease  approaches  its  close.  In  cases  of  long  duration 
the  morning  hours  are  often  free  from  fever,  a  circumstance  calculated 
to  mislead  a  physician  who  sees  his  patient  but  once  a  day.  A  pulse 
of  80  to  90  beats,  a  disturbed  sleep,  lack  of  appetite,  and  sensitiveness 
to  pressure  upon  the  sides  of  the  uterus  are,  however,  symptoms  which 
should  serve  as  a  warning  of  some  disturbing  cause,  and  should  lead 
the  physician  to  renew  his  visit  in  the  latter  part  of  the  day. 

If,  from  a  mistaken  notion  that  the  morbid  process  has  come  to  an 
end,  the  patient  is  allowed  prematurely  to  resume  her  household  duties, 
the  pains  across  the  abdomen  and  along  the  hip  and  thigh  return,  and 
an  examination  reveals  the  existence  of  exudation  in  the  pelvic  cavity 
or  upon  an  iliac  fossa. 

Errors  of  this  kind  are  most  frequent  in  cases  of  parametritis  as- 
sociated with  slight  peritoneal  inflammation,  as  the  local  pain  is  then 
insignificant,  and  the  initial  chill,  happening  on  the  third  or  fourth 
day,  is  apt  to  be  ascribed  to  engorgement  of  the  breasts. 

Relapses  after  the  complete  disappearance  of  febrile  disturbance 
occur  in  15  to  20  per  cent.  They  are  usually  shorter,  but  sometimes 
more  obstinate,  than  the  original  attack.  As  a  rare  exception  may  be 
mentioned  cases  with  evening  remissions  and  morning  exacerbations. 

In  circumscribed  pelvic  inflammations  the  pulse  rarely  exceeds  120 
beats  to  the  minute.  A  pulse  of  140,  of  more  than  half  a  day's  dura- 
tion, betokens  severe  septic  complications,  and  is  therefore  of  evil 
omen.  In  some  cases  the  slow  pulse  observed  after  labor  makes  its 
influence  felt  in  the  first  day  or  two  of  the  fever,  so  that  the  curious 
phenomenon  may  be  witnessed  of  a  temperature  of  104°  coinciding,  for 
a  time,  with  a  pulse  ranging  between  50  and  70  beats  to  the  minute. 

As  regards  other  symptoms,  headache  and  sleeplessness  are  rarely 
absent.  Profuse  sweating  follows  the  first  febrile  attack,  and  frequent- 
ly recurs  during  the  course  of  the  disease. 

Pain  is  present  at  the  onset  in  the  majority  of  cases,  and  is  then 

usually  most  violent.     The   spontaneous   pain,  which   is   due   to   the 

affection  of  the  peritonaeum,  subsides  in  great  part  in  the  course  of  one 

or  two  days,  but  the  sides  of  the  uterus  remain  sensitive  to  pressure. 

43 


Q^^  DISEASES  OF   CHILDBED. 

In  the  rare  cases  of  pure  parametritis,  however,  this  symptom  may 
be  absent  altogether.  The  pain,  like  that  from  the  inflammation  of 
serous  membranes,  is  of  a  lancinating  character.  Sometimes  it  is  asso- 
ciated only  with  the  contractions  of  the  uterus.  After-pains  occurring 
under  unusual  circumstances,  as  in  primipara?  or  after  the  third  day, 
are  to  be  regarded  with  suspicion. 

Vomiting  occurs  occasionally,  but  is  comparatively  rare,  unless  the 
peritonitis  becomes  diffused  and  spreads  to  the  region  of  the  stomach. 
The  appetite  is  lost,  and  only  returns,  as  a  rule,  with  the  departure  of 
the  fever.  The  tongue  is  coated  and  moist,  and  constipation  is  com- 
mon. In  other  cases  there  is  diarrhoea,  with  rumbling  in  the  bowels, 
but  without  pain  or  tenesmus.  The  urinary  secretion  is  rarely  inter- 
fered with,  and,  when  this  is  the  case,  it  indicates  the  extension  of  the 
inflammation  to  the  peritoneum  covering  the  bladder. 

Most  cases  of  perimetritis  and  parametritis  terminate  in  five  or  ten 
days,  the  fever  and  other  symptoms  gradually  subsiding.  When,  as 
may  happen  in  exceptional  instances,  the  temperature  falls  suddenly 
from  a  high  degree  to  one  below  the  normal  level,  the  body  grows  icy 
cold,  the  pulse  becomes  small  and  irregular,  and  symptoms  of  collapse 
develop.  But,  in  twelve  to  twenty-four  hours,  the  symptoms  of  collapse 
subside,  and  the  disease  reaches  its  end  with  a  disappearance  of  the 
alarming  manifestations. 

If  the  fever  subsides  within  a  week,  exudation  is  somewhat  rare. 
Its  continuance  beyond  that  date  should  lead  to  a  careful  exploration 
of  the  pelvic  organs.  The  exudation  is  usually  demonstrable  in  the 
course  of  the  second  week  or  at  the  beginning  of  the  third  week.  It 
is  recognized,  according  to  its  location,  by  external  or  by  internal  ex- 
amination, or,  where  the  deposit  is  considerable,  by  both  methods. 
In  many  cases  the  deposit  is  extra-peritoneal,  and  is  situated  between 
the  folds  of  the  broad  ligament,  above  and  to  the  sides  of  the  vaginal 
cul-de-sac.  It  has  generally  a  rounded  form,  though  with  less  con- 
vexity than  fibrous  and  ovarian  tumors.  Sometimes,  however,  the 
tumor  is  flat  below,  like  a  board.  It  seldom  exceeds  in  size  that  of  a 
large  apple.  In  fresh  exudations  the  sensation  produced  is  often  that 
of  a  hard  tumor  surrounded  by  a  softer  layer,  due  to  continued  succu- 
lence of  the  soft  parts.  In  a  few  weeks  they  may  reach  or  exceed  tlie 
hardness  of  a  fibroid  tumor.  The  older  the  tumor,  unless  suppuration 
sets  in,  the  less  sensitive  it  becomes.  Often  the  exudation  extends  to 
the  pelvic  walls.  The  uterus,  as  a  rule,  is  fixed,  and,  in  cases  of  large 
tumors,  becomes  pushed  toward  the  opposite  side,  while,  as  a  conse- 
quence of  later  shrinkage,,  the  fuudus  may  be  drawn  permanently 
toward  the  affected  side. 

The  cul-de-sac  of  the  vagina  is  rendered  broader  and  flatter  by  the 
pressure  of  the  deposit,  or,  Avhen  the  tumor  is  deep  enough,  the  vagi- 
nal surface  may  be  rendered  convex.     Behind  the  uterus  the  exudation 


PUERPERAL   FEVER.  675 

is,  as  it  were,  flattened  antero-posteriorly,  and  in  some  cases  it  may  be 
felt  in  tlie  form  of  rigid  bands  between  the  posterior  ligaments  which 
inclose  the  cul-de-sac  of  Douglas.  The  ante-uterine  tumors  have  a 
spherical  shape  and  depress  the  vagina  anteriorly. 

Tumors  situated  in  the  iliac  fossa  have  a  more  or  less  convex  form, 
and  may  be  of  such  considerable  size  that  the  swelling  may  be  recog- 
nized by  the  eye  through  the  abdominal  walls.  As  the  exudation  be- 
tween the  broad  ligaments  may,  in  these  cases,  have  been  slight  from 
the  beginning,  or  may  have  subsequently  disappeared  by  absorption, 
the  iliac  tumors  have  often,  apparently,  a  spontaneous  origin. 

Sometimes  the  uterus  is  surrounded  by  exudation,  and  the  entire 
pelvis  appears  as  though  it  were  a  mold  filled  with  a  solid  mass.  The 
fornix  is  then  often  pressed  downward,  and  irregular  rounded  massed 
are  to  be  felt  through  the  vaginal  walls. 

The  recognition  of  parametritic  tumors  through  the  abdominal 
coverings  is  possible  when  they  are  situated  above  Poupart's  ligament, 
in  the  upper  portion  of  tlie  broad  ligaments,  and  in  the  iliac  fossae. 

Unquestionably  many  supposed  parametritic  tumors  have  been 
really  cases  of  salpingitis  with  accompanying  intraperitoneal  deposit 
of  lymph. 

The  pain  and  the  functional  disturbances  in  the  pelvic  organs  de- 
pend upon  the  size  and  situation  of  these  inflammatory  deposits.  Of 
the  functional  troubles,  may  be  mentioned  frequent  and  painful  mic- 
turition, obstinate  constipation  and  difficult  defecation,  contractures 
of  the  ilio-psoas  muscles  when  the  exudation  is  seated  beneath  the 
sheath  or  between  the  muscle  and  the  pelvic  bones,  disturbances  of 
motility  in  the  abductor  muscles,  paresis  of  the  lower  extremities,  and 
radiating  pains  in  the  upper  portion  of  the  thigh  and  in  the  renal  and 
lumbar  regions,  produced  by  pressure  upon  the  obturator,  the  crural, 
the  cutaneous,  and  the  sciatic  nerves. 

So  long  as  fever  is  present,  the  exudation  rarely  diminishes.  If  ab- 
sorption takes  place  in  one  point,  growth  almost  certainly  follows  in 
some  other  direction.  When,  however,  the  apyretic  period  is  reached, 
the  exudation,  as  a  rule,  disappears  rapidly,  so  that  often  in  the  course 
of  six  weeks  no  trace  of  its  existence  remains.  In  a  smaller  number, 
the  solid  mass  may  persist  for  months  or  even  years. 

After  the  fever  has  departed  the  patient  usually  feels  well.  The 
sleep  and  appetite  return,  the  night-sweats  disappear,  the  pulse  often 
falls  to  50  or  60  beats,  and  the  temperature  is  in  many  cases,  for  a  time, 
subnormal  in  character. 

Where  the  fever  persists  for  from  five  -to  six  weeks,  there  is  always 
a  suspicion  of  abscess  formation.  With  the  exception  of  afternoon 
fever  and  night-sweats,  the  patient  may  feel  very  comfortable.  Then 
the  exudation  becomes  sensitive,  the  spontaneous  pains  recur,  sleep 
is  lost,  and  locomotion,  defecation,  and  urination  occasion  acute  suffer- 


ere 


DISEASES  OF   CHILDBED. 


ing.  The  fever  becomes  violent,  chills  announce  the  presence  of  pus, 
and  finally,  about  the  seventieth  or  eightieth  day,  perforation  of  the 
abscess  takes  place.  The  usual  seat  at  Avhich  the  pus  is  discharged 
is  Just  above  Poupart's  ligament ;  next,  in  frequency,  perforation  takes 
place  into  the  colon,  and  in  rare  instances  into  the  bladder,  the  uterus, 
and  vagina.  Fortunately,  of  very  rare  occurrence  is  the  discharge  of 
pus  into  the  peritoneal  cavity,  which  is  naturally  followed  by  acute 
peritonitis.  Another  likewise  unfrequent  but  most  dangerous  acci- 
dent is  the  septic  infection  of  the  abscess — an  occurrence  referred  by 
Olshausen  to  the  diffusion  of  intestinal  gases  through  the  Avails  of  the 
tumor. 

In  suppuration  of  parametritic  exudations  the  pus  commonly  forms 
in  small  scattered  collections,  and  rarely  gives  rise  to  large  abscesses. 

Although  parametritis  and  perimetritis  are  usually  found  associated 
together,  there  are  always  cases  in  which  the  one  form  of  inflammation 
so  far  predominates  over  the  other  as  to  justify  an  attempt  to  establish 
a  clinical  distinction  between  them. 

In  the  beginning  of  the  attack,  sharp  pain,  high  fever,  and  tym- 
panitic distention  of  the  lower  abdomen  are  symptomatic  of  inflamma- 
tion in  the  pelvic  peritonaeum.  AVhether  the  cellular  tissue  is  simul- 
taneously implicated  can  only  be  determined  by  a  digital  examina- 
tion after  the  abdominal  sensitiveness  has  subsided.  The  absence  of 
the  objective  signs  of  cellulitis  would  then  contribute  to  prove  that 
the  case  had  been  one  in  which  the  peritonaeum  had  l)een  in  the  main 
affected.  On  the  other  hand,  moderate  fever,  pain  elicited  only  on 
pressure,  and  tympanitic  distention  confined  to  the  colon,  coinciding 
with  exudation  between  the  folds  of  the  broad  ligament,  would  be  in- 
dicative of  a  nearly  pure  cellulitis. 

A  palpable  exudation  is  by  no  means  the  necessary  product  of  peri- 
toneal inflammation.  Indeed,  in  many  cases,  the  distinctive  symptoms 
of  the  latter  may  be  present  for  from  four  to  eight  days,  and  may  then 
subside  without  leaving  a  trace  of  its  existence  at  the  pelvic  brim. 

The  demonstration  of  a  fluid  effusion  by  noting  the  change  of  level, 
upon  shifting  the  position  of  the  patient,  is  rarely  possible,  either  be- 
cause the  quantity  is  too  small  or  because  it  quickly  becomes  confined 
by  pseudo-membranous  adhesions  between  the  intestines. 

Bandl  *  mentions  as  a  sign  of  local  peritonitis,  sometimes  notice- 
able, a  number  of  resistant  points  or  tumors  near  the  pelvic  brim  or 
above  one  of  the  iliac  foss«,  due  to  a  matting  together  of  the  intestines 
or  to  their  adhesion  to  the  uterine  appendages.  They  are  distinguished 
from  solid  tumors  by  their  emitting  a  tympanitic  sound  upon  percus- 
sion, and  by  their  changing  position  in  consequence  of  an  accumulation 
of  urine  in  the  bladder  or  of  faces  or  gases  in  the  bowels.  Again,  all 
tumors  may  be  reckoned  as  intraperitoneal  which  very  rapidly  form 
*  Handbuch  der  Frauenkrankheiten,  red.  von  Billroth,  5ter  Abschnitt. 


PUERPERAL   FEVER.  677 

behind  or  to  the  side  of  the  uterus  from  inclosed  exudation-products, 
and  which  at  the  same  time  rise  far  above  the  level  of  the  pelvic  brim. 
If,  however,  they-  start  from  the  cul-de-sac  of  Douglas,  and  do  not 
much  exceed  the  linea  terminalis,  or  if  they  occupy  an  iliac  fossa,  it 
becomes  very  difficult  to  decide  whether  they  are  of  intra-  or  extra- 
peritoneal origin.  The  peritoneal  exudation,  however,  long  remains 
soft  and  fluctuating.  It  arises,  as  a  rule,  behind  the  uterus,  and  does 
not  exhibit  a  tendency  to  spread  to  the  sides  or  to  the  anterior  or  pos- 
terior pelvic  walls. 

Still  more  difficult  is  it  to  decide  as  to  the  seat  of  exudations  met 
with  beneath  the  abdominal  walls.  When  diffused  and  continuous 
with  a  pelvic  deposit,  the  diagnosis  is  uncertain.  It  is  only  safe  to  as- 
sume the  peritoneal  origin  of  extravasations  of  a  rounded  form,  of  a 
fluctuating  consistence,  and  when  they  are  situated  high  uj)  and  are 
disconnected  from  exudation  at  the  pelvic  brim.  An  opening  of  the 
abscess  through  the  navel  would  indicate  a  peritoneal  source,  while 
the  discharge  through  the  abdominal  parietes  would  point  to  a  seat  in 
the  connective  tissue. 

After  the  perforation  of  an  abscess,  the  fever  and  pain  subside ;  the 
wound,  if  external,  either  closes  in  the  course  of  one  or  two  weeks,  or 
fistulas  form  which  become  the  source  of  protracted  suppuration. 

In  psoas  abscesses,  the  exudation  extends  beneath  the  sheath  of  the 
muscle  or  between  the  iliacus  and  the  bone.  In  puerperal  patients, 
they  proceed  from  an  inflammation  originating  in  the  broad  ligament. 
They  are  situated  too  deep  to  be  easily  palpated.  The  pains  they 
occasion  are  referred  rather  to  the  hip  or  knee  than  to  the  abdomen. 
The  contracture  of  the  psoas  muscle  furnishes  a  diagnostic  sign  which 
distinguishes  this  form  from  the  superficial  abscesses  of  the  iliac  fossa?. 
The  pus  eventually  is  discharged  beneath  Poupart's  ligament,  in  the 
lower  portion  of  the  inguinal  fossa,  at  some  point  upon  the  crest  of  the 
ileum,  or  exceptionally  along  the  thigh.  Often  the  discharge  is  main- 
tained for  months. 

The  Symptoms  of  General  Peritonitis  (Suppurative). — This  form 
generally  begins  with  the  usual  symptoms  of  pelvic  inflammation,  but 
the  tenderness,  which  at  first  was  limited  to  the  side  of  the  uterus,  grad- 
ually spreads  over  the  entire  abdomen.  The  abdominal  pain  is  of  a 
tearing,  lancinating,  sometimes  colicky  character.  It  is  increased  by 
the  slightest  bodily  movement,  by  jarring  of  the  bed,  or  even  by  the 
weight  of  the  bedclothes. 

As  a  consequence  of  the  peritoneal  inflammation  and  of  the  ac- 
companying exudation,  the  muscular  walls  of  the  bowels  become  para- 
lyzed, and  tympanitic  distention  results  from  the  accumulation  of  gases. 
In  the  dependent  portions  of  the  peritoneal  cavity  it  is  often  possible 
to  demonstrate,  by  percussion,  the  presence  of  fluid  exudation,  though 
distinct  fluctuation  is  rarelv  to  be  made  out.     The  size  of  the  abdomen 


g/j.g  DISEASES  OF   CHILDBED. 

is  due  much  more  to  the  tympanites  than  to  the  amount  of  effusion. 
Sometimes  the  liver,  with  the  diaphragm,  is  pushed  by  the  swollen  bow- 
els to  the  level  of  the  fourth  or  third  rib,  and  exercises  such  a  degree 
of  compression  upon  the  posterior  portion  of  the  lungs  as  to  place  the 
patient  in  danger  of  suffocation.  The  respirations  are  jerky  and  at- 
tended with  a  moaning  sound. 

The  loss  of  muscular  power  in  the  intestines  permits  the  contents 
of  the  middle  portion  to  pass  unchecked  toward  the  duodenum,  and 
thence,  upon  accidental  contractions  of  the  abdomen,  tliey  may  jjass  to 
the  stomach  and  be  ejected  by  vomiting.  The  first  vomited  matter  has  a 
dark-green  color,  and  that  ejected  afterward  presents  the  color  of  in- 
testinal matter.  Constipation  at  the  outset  may  be  subsequently  fol- 
lowed by  colliquative  diarrhoea. 

The  fever  begins,  as  a  rule,  though  not  always,  with  an  intense  chill, 
the  temperature  rises  to  104°,  and  the  pulse  becomes  small,  hard,  and 
resistant.  Its  frequency  rapidly  increases,  varying  from  1"^0  to  KiO 
beats  to  the  minute.  The  skin  is  sometimes  dry,  sometimes  drip])ing 
with  perspiration.  In  fatal  cases,  as  the  end  approaches,  the  tempera- 
ture frequently  falls,  while  tlie  pulse  becomes  more  rapid,  the  face  as- 
sumes a  pinched,  anxious  exjjresrfion,  sweat  gathers  upon  the  foreliead, 
the  extremities  grow  icy  cold,  and  the  patient  dies  in  collapse.  The 
duration  of  peritonitis  averages  not  more  than  from  four  to  six 
days. 

In  cases  of  recovery  the  pulse  imi)roves,  the  vomiting  ceases,  and 
the  tympanites  disappears.  The  diffuse  exudation  tlien  becomes  con- 
verted into  circumscribed  tumors,  which,  on  palpation,  are  felt  on  the 
side  of  the  pelvis  and  extending  upward  to  the  level  of  the  umbilicus. 
Upon  internal  examination,  the  uterus  is  often  found  (lej)ressed  by  tiie 
weight  of  the  fluid,  which  likewise  may  bulge  the  nd-de-sac  of  Douglas 
into  the  pelvic  cavity.  Sometimes  the  exudation  may  ]>ecome  encysted 
above  the  pelvis  and  leave  the  contents  of  the  latter  free.  In  still  otiier 
cases,  the  uterus  may  become  attached  high  up  to  the  abdominal  walls, 
so  that  the  vaginal  portion  disappears  and  tlie  os  is  reached  with  diffi- 
culty. 

The  peritoneal  exudation  may,  as  in  pelvic  inflammations,  become 
absorbed  and  disappear.  When,  however,  it  is  surrounded  by  loops  of 
intestines,  it  is  apt  to  undergo  purulent  and  septic  changes,  and  the  ab- 
scesses may  then  become  discolored  and  filled  with  stinking  gases.  The 
patient,  whose  previous  improvement  has  been  watched  with  delight, 
now  loses  appetite,  the  pulse  becomes  frequent,  the  strength  fails,  and 
death  may  follow  from  septic  fever  or  from  rupture  of  abscess  into  the 
abdominal  cavity. 

In  the  pyaimic  form — a  still  more  deadly  variety  of  peritonitis — the 
symptoms  differ  materially  from  those  which  have  been  recounted. 
As,   however,   it   constitutes   only   a   single   one   of   the   pathological 


PUERPERAL   FEVER. 


679 


changes  connected  witli  the  poisoning  of  the  blood  througli  the  lym- 
phatic system,  its  consideration  belongs  properly  to  the  stndy  of  the  sep- 
tic infection. 

The  Symptoms  of  Septicaemia  Lymphatica  (Septic).— The  symptoms 
of  blood-poisoning  in  the  infectious  diseases  of  childbed  vary  to  a  con- 
siderable extent  according  to  the  channel  through  which  the  septic 
•germs  enter  the  general  circulation.  In  the  murderous  epidemics  which 
prevail  in  lying-in  hospitals  the  lymphatics  are,  as  a  rule,  the  vessels 
primarily  invaded.  It  is  to  this  form  that  the  cases  already  described 
belong,  where,  with  diphtheritic  patches  upon  the  utero-vaginal  canal 
and  sero-purulent  oedema  of  the  parametrium,  there  are  associated  pye- 
mic peritonitis  and  deformation  of  the  blood-corpscules  ;  or  where,  fol- 
lowing the  migrations  of  the  round  bacteria,  the  serous  cavities  become 
successively  involved,  septic  vegetations  gather  upon  the  heart,  and  the 
glomeruli  of  the  kidneys  become  choked  with  micrococci.  The  lym- 
phatic form  of  septicsemia  develops  soon  after  labor,  and  is  always 
ushered  in  by  a  chill.  The  temperature  rises  to  104°  or  even  higher,  and 
the  pulse  is  thin  and  frequent.  The  abdomen  swells  rapidly,  without 
being  especially  painful.  Indeed,  painless  distention  of  the  intestines 
is  one  of  the  characteristics  of  an  acute  invasion  of  the  lymphatics. 
Peritoneal  effusion  is  absent  in  cases  which  run  a  rapid  course,  and  is 
distinctly  recognizable  only  in  a  peritonitis  of  long  continuance.  The 
effusion  is  not  so  much  due  to  exudation  as  to  a  transudation  of  serum 
with  which  micrococci  are  commingled.  At  the  same  time  the  tongue 
is  moist,  but  slightly  coated,  and  at  times  quite  clean.  Sometimes  there 
is  diarrhoea,  due  to  catarrh  or  to  a  diphtheritic  affection  of  the  colon. 
When  the  bowels  have  been  constipated,  the  administration  of  a  pur- 
gative may  provoke  discharges  which  it  may  be  found  difficult  to  arrest. 
The  skin  is  bathed  in  perspiration.  At  the  beginning  and  during  the 
course  of  the  disease,  bleeding  at  the  nose  is  not  of  infrequent  occur- 
rence. 

Toward  the  end,  tlie  pulse  runs  up  to  140  to  160  beats,  while  in 
many  cases  the  temperature  falls.  Immediately  after  death  the  heat 
of  the  body  may  for  a  short  time  exceed  the  highest  point  reached  dur- 
ing life.  The  respirations  are  superficial  and  jerky.  In  many  instances 
the  face,  the  neck,  and  the  fingers  are  blue  from  defective  oxygenation 
of  the  blood.  At  the  same  time,  the  skin  becomes  clammy  and  the  ex- 
tremities cold. 

The  sensorium,  in  cases  which  run  a  rapid  course,  is  usually  affect- 
ed at  an  early  period.  The  patients  appear  somnolent,  are  restless  in 
bed,  have  light  delirium,  and  respond  only  when  spoken  to  loudly.  As 
a  rule,  they  make  but  little  complaint,  and,  were  it  not  for  the  dyps- 
noea,  would  have  nothing  to  disturb  their  sense  of  comfort.  Very 
few,  even  as  death  approaches,  have  any  idea  of  the  danger  that 
threatens  them.     Now  and  then,  in  place  of  stupor,  great  restlessness, 


ggQ  DISEASES  OF  CHILDBED. 

and  even  a  maniacal  condition,  is  developed.     Albumen  is  usually  found 

in  the  urine. 

Pleurisy,  so  frequently  associated  with  lymphatic  septicaemia,  is  fre- 
quently double,  more  rarely  single,  and  begins,  as  a  rule,  with  sharp 
pain  in  the  side  and  an  aggravation  of  the  previous  dyspnoea.  Pericar- 
ditis is  less  frequent,  and  occurs  usually,  without  symptoms,  toward 
the  close  of  life.  The  joint  affections  are  characterized  by  redness  and 
swellino-,  and  by  pain,  Avhich  is  sometimes  so  great  that  touching  the 
inflamed  part  suffices  to  arouse  the  patient  from  sopor.  Sometimes 
fluctuation  is  felt,  but  death  occurs  before  perforation  and  discharge  of 
the  pus. 

The  most  frequent  ending  is  death,  which  follows  in  from  two  to 
twenty-one  days,  and,  as  a  rule,  between  four  and  seven  days,  liecovery 
is,  however,  possible. 

The  Symptoms  of  Septicaemia  Venosa  (Phlebitis  uterina,  Pyaemia 
metastatica).— The  putrid  infection  of  a  thrombus  at  the  placental  site 
may  take  place  within  twenty-four  to  forty-eight  hours  after  labor. 
Usually,  however,  the  approach  is  insidious,  and  the  disease  develops 
from  an  apparently  insignificant  endometritis  or  parametritis ;  or  the 
patient,  with  the  exception,  perhaps,  of  a  tired  feeling,  of  slight  chilly 
sensations,  and  of  profuse  perspiration,  may  not  have  been  conscious  of 
any  indisposition  for  days  preceding  the  attack,  or  even  until  the  first 
getting  up  from  childbed.  The  initial  chill,  in  typical  cases,  is  charac- 
terized by  its  violence  and  duration.  In  some  cases  it  may  last  for 
hours.  It  is  accompanied  and  followed  by  high  temperature,  the  fe- 
brile attack  ending  with  profuse  perspiration  as  in  intermittent  fever, 
with  which  it  is  apt  to  be  confounded.  The  fall  in  temperature  often 
assumes  the  form  of  a  prolonged  remission. 

In  many  cases,  the  pulse  rises  and  falls  with  the  variations  in  the 
body  heat,  while,  in  others,  it  remains  permanently  above  the  average. 
A  frequent  pulse  is  always  a  suspicious  symptom  in  childbed,  even  where 
the  other  symjitoms  are  apparently  normal. 

Erratic  chills  announce  the  lodgment  of  emboli  in  distant  organs. 
With  the  formation  of  metastatic  abscesses  in  the  lungs  and  other 
parenchymatous  organs,  the  t3']3ical  character  of  the  disease  changes. 
In  place  of  chills  occurring  at  irregular  intervals,  followed  by  remis- 
sions and  periods  of  apparent  improvement,  the  fever  is  continuous,  the 
pulse  becomes  small  and  rapid,  while  sopor,  slight  delirium,  a  dry  skin, 
a  dry,  brown,  cracked  tongue,  and  a  moderately  tymjianitic  abdomen, 
give  the  case  the  appearance  of  one  of  typhus  fever. 

Peritonitis  is  present  in  hardly  one  third  of  the  cases.  The  abdo- 
men is  therefore  flat  and  soft,  and  often  is  not  sensitive  upon  pressure. 
Icterus,  due  to  disintegration  of  the  blood-corpuscles,  is  an  ominous 
symptom. 

Death  usually  occurs  in  the  second  or  third  week.     In  the  typhus- 


PUERPERAL  FEVER.  681 

like  cases,  however,  it  may  follow  the  first  attack  speedily.  Recovery  is 
possible  where  the  organs  secondarily  affected  are  not  of  too  great  im- 
portance. 

A  combination  of  the  lymphatic  and  venons  forms  of  septicaemia  is 
not  uncommon  in  cases  running  a  protracted  course. 

The  Symptoms  of  Pure  Septica3mia.— Under  the  title  of  pure  septi- 
caemia should  be  placed  cases  in  which  the  absorption  of  morbific  ma- 
terials into  the  blood  gives  rise  to  symptoms  of  intense  blood-poisoning 
without  the  development  of  local  lesions.  A  common  exaniiDle  of  this 
form  is  met  with  in  the  fever  which  results  from  the  presence  in  the 
uterus  of  decomposing  coagula  or  portions  of  retained  ovum,  the  fever 
subsiding  with  the  removal  of  the  disturbing  cause.  The  symptoms 
are  often  similar  to  those  produced  by  the  injection  of  putrid  materials 
containing  rod-like  bacteria  into  the  vessels  of  animals.  As  the  long 
bacteria  do  not  possess  the  capacity  of  self -reproduction  in  the  blood,  to 
produce  fatal  results  the  quantity  of  putrid  fluid  injected  must  be  large 
or  be  frequently  repeated.  This  form  is  said  not  to  be  inoculable.  In 
like  manner  we  sometimes  meet  with  cases  of  intense  septic  poisoning 
followed  by  speedy  death,  in  which  the  post-mortem  examination  re- 
veals only  changes  in  the  blood  and  softening  of  the  parenchymatous 
organs. 


CHAPTER  XXXVI. 

PUERPERAL  FEVER  {Continuecl). 

Causes. — The  atmosphere.— Inoculation.— Season  of  the  year. — Social  state. — Rela- 
tions to  zymotic  diseases.— The  prevention  of  puerperal  fever.— Treatment.— 
Vaginal  and  uterine  injections.— Iodoform  bacilli;  opium;  leeches;  stupes; 
laxatives ;  quinine ;  salicylate  of  sodium  ;  Warburg's  tincture ;  veratrum 
viride;  digitalis;  antipyrine  ;  alcohol  ;  cold. — Treatment  of  peritoneal  effusions 
and  inflammatory  exudations. 

Causes  of  Puekperal  Fever. 
The  Atmosphere.— Micrococci  multiply  in  hospitals  when  organic 
materials  favorable  to  their  growth  are  present  in  sufficient  quantities. 
Perrin,  Quenquand,  and  others  have  shown  that  the  hospital  wards  in 
Paris,  especially  those  upon  the  surgical  and  maternity  divisions,  con- 
tain an  infinite  number  of  vibrios,  bacteria,  and  all  the  coccus  forms 
(Charpentier).  Robin  has  demonstrated  the  existence  of  albuminoid 
matters  in  water  condensed  upon  vessels  containing  freezing  mixtures 
and  placed  in  overcrowded  wards  of  hospitals.  When  the  results  of 
crowding  become  manifest,  these  albuminoid  matters  not  only  impart 
a  fetid  odor  and  putrefy  with  great  rapidity,  but  rapidly  impart  putre- 
faction  to   healthy   muscle   and  normal  blood   with  which  they  are 


gg2  DISEASES  OF  CHILDBED. 

brought  into  contact.  Pasteur  was  able,  by  the  microscopic  examina- 
tion of  the  lochia  from  patients  in  the  services  of  Ilervieux  and  Lucas- 
Champonniere,  to  predict,  from  the  character  of  the  contained  organ- 
isms, an  impending  attack  of  fever  in  advance  of  the  slightest  symptom 
betokening  danger. 

The  quality  of  the  agents  which  pervade  the  air  where  hospital 
patients  are  confined  is  an  important  element  in  the  genesis  of  febrile 
outbreaks.  The  bacterium  termo,  which  causes  putrefaction,  is  not  in 
itself,  as  we  have  already  mentioned,  a  source  of  danger.  A  stinking 
odor  is  not  necessarily  incompatible  with  a  low  mortality  rate.  The 
importance  of  the  common  forms  of  bacteria,  according  to  Pasteur,  re- 
sults from  the  fact  that  by  their  power  to  consume  oxygen  they  pave 
the  way  for  the  active  development  of  the  pernicious  germs,  nearly  all 
of  which  thrive  only  in  media  in  wliicli  that  element  has  been  materi- 
ally diminished.  Again,  there  is  reason  to  believe  that  the  same  germs 
are  not  always  equally  active  for  evil.  The  resistance  of  micrococci  to 
carbolic  and  salicylic  acids  is  found,  experimentally,  to  depend  in  a 
measure  upon  the  nature  of  the  vehicle  in  whicli  they  are  cultivated 
(Buchholz).  The  action  of  septic  fluids  varies,  too,  with  the  age  of 
the  infusions,  with  the  materials  employed,  and  with  the  conditions 
under  which  the  poison-germs  are  generated. 

It  was  unquestionably  the  lochial  discharge  whicli,  before  the  days 
of  antisepsis,  made  it  such  a  difficult  task  to  keep  a  maternity  ward  in 
a  healthful  condition.  Putrid  blood  has  been  found  to  be  the  most 
favorable  material  for  septic  experiments.  In  the  summer  months,  so 
long  as  the  windows  were  open  and  the  air  was  diluted  by  the  continu- 
ous passage  of  fresh  currents,  the  patients  usually  enjoyed  immunity 
from  puerperal  fevers.  In  the  autumn,  so  soon  as  it  Ijccame  necessary 
to  close  the  windows  partially,  on  account  of  the  cool  nights,  it  was  not 
uncommon  for  the  more  trivial  disturbances,  such  as  so-called  milk 
fever,  the  hospital  pulse,  and  catarrhal  affections  of  the  genitalia,  to 
manifest  themselves.  Through  the  months  of  February,  March,  and 
April  the  mortality  was  usually  greatest.  During  the  winter  months 
there  was,  as  a  rule,  crowding  of  patients,  insufficient  ventilation,  stag- 
nation of  the  air,  and  the  rapid  accumulation  of  disease-germs.  That 
the  later  winter  months  should  prove  the  most  perilous  is  in  accord- 
ance not  only  with  the  theory  of  continuous  accumulation,  but  with 
the  experimental  fact  that  weeks  sometimes  elapse  before  a  decompos- 
ing substance  acquires  the  highest  degree  of  virulence. 

Apart  from  the  nosocomial  malaria  of  hospitals,  there  is  reason  to 
believe  in  the  influence,  at  times,  of  certain  general  widespread  atmos- 
pheric states  which  affect  the  entire  community.  In  the  year  1871 
the  mortality  from  childbed  in  Xew  York  was  399 ;  in  1872,  503 ;  in 
1873,  431 ;  in  1874,  439 ;  and  in  1875,  420.  Now,  the  excess  in  the 
deaths  for  1872  was  due  wholly  to  an  increase  in  the  cases  of  mctria, 


PUERPERAL  FEVER.  683 

those  from  ordinary  accidents  remaining  nearly  the  same  as  in  the 
preceding  years.  The  disease  certainly  did  not  extend  into  the  city 
from  the  hospitals  serving  as  foci,  for  the  mortality  at  Bellevue  Hos- 
pital was  hardly  more  than  half  the  usual  average.  There  was  no 
especial  mortality  that  year  from  either  diphtheria,  erysipelas,  or  scar- 
latina, but  the  aggregate  mortality  was  the  largest  known  in  the  his- 
tory of  the  city.  There  are  no  positive  data  connecting  the  civil  deaths 
from  puerperal  fever  in  1872  with  parasiticism,  but  the  prevalence  of 
epizootics,  of  epidemic  catarrhal  affections,  of  peculiarly  fatal  forms  of 
pneumonia  and  other  diseases  which  are  now  attributed  to  the  presence 
of  minute  organisms  in  the  atmosphere,  renders  such  a  soi;rce  highly 
jirobable. 

It  is  proper  to  say  here  that,  though  the  argument  is  very  strong 
in  favor  of  regarding  the  genitalia  of  puerperal  women  as  the  exclusive 
point  of  entry  of  infectious  materials  into  the  system,  it  seems  impos- 
sible at  the  present  time  to  make  all  the  facts  coincide  with  such  a 
theory.  I  have  the  records  of  a  number  of  cases  occurring  during  an 
epidemic  of  puerperal  fever  in  which  patients  were  either  attacked 
with  fever  previous  to  parturition,  or  in  whose  cases  the  unusual  length 
of  labor,  the  frequency  of  post-jjartum  hemorrhage,  and  the  imperfect 
contraction  of  the  uterus  immediately  after  confinement,  were  signs  of 
some  abnormal  influence  exercised  upon  the  economy  at  an  early  period 
of  labor  previous  to  the  existence  of  traumatism.  That  deleterious  ma- 
terials may  find  other  channels  for  entering  the  system  than  a  wounded 
surface  is  evidenced  by  the  cachectic  condition  not  unfrequently  pro- 
duced in  physicians  by  too  assiduous  attendance  in  dissecting-rooms 
and  places  in  which  post-mortem  examinations  are  conducted.  One 
severe  and  rapidly  fatal  case  of  puerperal  fever  which  occurred  in  Belle- 
vue Hospital  I  find  it  impossible  to  attribute  to  any  other  cause  than 
that  the  woman,  for  five  months  previous  to  her  confinement,  served 
as  a  helper  in  a  lying-in  ward.  The  post-mortem  examination  dis- 
closed no  special  local  lesions,  but  her  symptoms  were  those  of  in- 
tense septicaemia.  French  writers  report  instances  of  toxemic  condi- 
tions developing  in  young  midwives  during  puerperal-fever  epidemics. 
While  we  are  not  prepared  to  go  as  far  as  Tarnier,  who  says,  "  It  is 
probable  that  the  hmgs,  by  their  extent  and  activity,  offer  conditions 
most  favorable  to  absorption,  and  that  often,  if  not  always,  it  is  by 
them  that  poisoning  occurs,"  it  does  not  yet  seem  time  to  give  up  the 
idea  that,  under  exceptional  circumstances,  the  respiratory  and  the 
digestive  tracts  may  allow  the  passage  of  materials  of  a  septic  char- 
acter. 

Inoculation.— Unquestionably  the  most  frequent  source  of  puer- 
peral fever  is  by  inoculation  ;  and  yet,  no  longer  than  thirty  years  ago, 
the  doctrine  was  combated  as  a  pernicious  heresy  by  both  Meigs  and 
Hodge,  of  Philadelphia,  at  that  time  regarded  as  the  best  authorities 


gg^  DISEASES  OF  CHILDBED. 

upon  obstetrical  questions  in  this  country.  Hodge,  addressing  his 
students,  said  :  "  The  result  of  the  whole  discussion  will,  I  trust,  serve 
not  only  to  exalt  your  views  of  the  value  and  dignity  of  our  profession, 
but  to  divest  your  minds  of  the  overpowering  dread  that  you  can  ever 
become,  especially  in  women  under  the  extremely  interesting  circum- 
stances of  gestation  and  parturition,  the  ministers  of  evil— that  you 
can  ever  convey,  in  any  possible  manner,  a  horrible  virus,  so  destruct- 
ive in  its  effects  and  so  mysterious  in  its  operations  as  that  attributed 
to  puerperal  fever " ;  and  Meigs,  in  his  letters  to  students,  writes : 
"  I  prefer  to  attribute  them  to  accident  or  to  Providence,  of  which 
I  can  form  a  conception,  rather  than  to  a  contagion  of  which  I  can 
not  form  any  clear  idea,  at  least  as  to  this  particular  malady."  Con- 
trasted with  these  rhetorical  utterances,  in  an  essay  published  in  1843, 
by  Prof.  Oliver  Wendell  Holmes,  entitled  "  Puerperal  Fever  as  a 
Private  Pestilence,"  the  opposing  testimony  in  favor  of  contagion 
was  presented  with  equal  literary  and  scientific  skill.  The  evidence 
was  complete  and  conclusive,  and  has  exercised  a  most  beneficial  in- 
fluence upon  the  practice  of  midwifery  in  America.  With  his  many 
claims  to  our  admiration  and  esteem,  there  is  probably  no  title  which 
Professor  Holmes  wears  with  greater  pride  than  th^t  of  pioneer  in  a 
movement  that  has  done  so  much  to  prevent  the  slaughter  of  innocent 
women  and  the  wrecking  of  happy  homes. 

The  ordinary  carriers  of  infection  are  unquestionably  the  unclean 
hands,  instruments,  utensils,  clothing,  wash  material,  and  the  like 
which  are  brought  in  contact,  during  or  after  labor,  with  the  genitals  of 
the  female. 

Barnes  and  other  English  writers  lay  considerable  stress  upon  cases 
of  puerperal  fever  due  neither  to  contagion  nor  to  atmospheric  con- 
ditions, but  to  the  poisoning  of  the  patient  by  her  own  secretions. 
There  is  justification  for  this  view  in  the  fact  that  even  normal  lochia 
contain  bacteria,  and,  when  inoculated  into  animals,  produce  in  them 
affections  of  an  ichorrhfemic  and  septictemic  nature.  When  death 
takes  place,  the  tissues  of  animals  thus  treated  are  found  to  be  filled 
with  round  bacteria.  Furthermore,  the  disease  artificially  produced  is 
in  itself  infectious,  and  can  be  continuously  propagated  in  other  ani- 
mals. But  it  may  be  asked,  "  Does  not  tliis  admission  cut  both  ways? 
How  is  it  possible,  if  even  normal  lochia  possess  virulent  qualities,  that 
childbed  is  ever  unattended  by  accessions  of  fever  ?  "  To  this  we  can 
only  answer  that  the  reasons  for  immunity  in  ordinary  cases  are  only 
known  in  part.  Karewski  *  and  other  experimental  investigators  have 
shown  that  the  virulence  of  the  lochia  increases  proportionately  to  the 
number  of  days  that  have  transpired  since  the  birth  of  the  child,  and 

*  Experimentelle  Untersuchun£:en  iiber  die  Einwirkungen  puerperaler  Secrete 
auf  den  thierischen  Organismus,  Zeitschr.  f.  Geb.  und  Gvnaek.,  Bd.  vii,  2ter  Th., 
S.  331. 


PUERPERAL  FEVER.  685 

that,  during  the  first  three  days,  the  locliia  are  comparatively  harmless. 
Meantime,  the  retraction  of  the  uterus,  the  closure  of  the  sinuses,  and 
the  formation  upon  the  wounded  surfaces  of  protecting  granulations, 
all  act  as  natural  barriers  to  the  penetration  of  poison-germs.  But, 
aside  from  these  reasons,  there  is  undoubtedly  an  unknown  quantity 
calling  for  further  investigation,  which,  in  the  absence  of  positive 
knowledge,  we  are  content  to  term  the  predisposition  of  the  individual 
patient.  The  vagina  after  childbirth  possesses  all  the  conditions  most 
favorable  for  the  production  of  putrefaction,  viz.,  the  access  of  air, 
fostering  warmth,  and  stagnating  fluids  charged  with  dead  tissue.  It 
is  probable  that  the  first  of  these  needful  conditions  is,  in  normal  la- 
bors, happily  wanting  in  the  uterine  cavity.  In  these  days  of  intra- 
uterine medication  it  is  well  to  bear  in  mind  the  relatively  greater 
frequency  of  infection  through  vaginal  and  cervical  wounds,  as  com- 
pared with  that  which  takes  place  through  the  denuded  intra-uterine 
surface.  The  term  auto-infection  may,  with  propriety,  be  employed 
as  a  distinctive  appellation  to  designate  those  attacks  of  fever  which, 
in  the  absence  of  any  demonstrable  cause,  occur  in  the  early  days  of 
childbed,  and  which  there,  quoad  vitam,  pursue  a  favorable  course, 
and  to  cases  of  so-called  late  infection — i.  e.,  where,  after  the  fifth  day, 
the  accidental  opening  of  a  healing  wound  permits  the  tardy  absorption 
of  poisonous  secretions ;  but  with  the  reserve  that  the  primary  cause 
is,  in  point  of  fact,  atmospheric,  and  the  predisposing  condition  the 
susceptibility  of  the  individual.  Cases  of  auto-infection  are  in  this 
country  extremely  rare,  if  not  unknown  altogether,  in  salubrious  or 
rural  districts. 

Seasons. — On  another  occasion  I  have  shown  that  in  New  York 
city  the  death-rate  from  puerperal  fever  is  nearly  twice  as  great  during 
the  six  months  from  December  to  May,  inclusive,  as  from  June  to 
November.  The  greatest  mortality  occurred  in  February  and  March, 
comprising .  rather  more  than  one  fourth  the  entire  amount.  The 
smallest  number  of  deaths  occurred  in  September  and  October,  in 
which  months  but  one  thirteenth  of  the  entire  number  took  place. 

Social  State. — That  puerperal  fever,  in  its  harvest  of  death,  does 
not  spare  the  wealthy  and  well-to-do  classes  is  too  familiar  a  truth  to 
be  worthy  of  discussion.  That,  however,  the  Avealthy  do  enjoy  special 
immunities  as  compared  with  the  less-favored  members  of  society,  I 
have  shown  by  comparisons  made  between  sections  of  the  city  which, 
though  lying  side  by  side,  exhibit  in  a  marked  degree  the  two  extremes 
of  wealth  and  poverty.  Thus,  the  mortality  among  the  representatives 
of  the  lower  social  strata,  in  proportion  to  population,  was  from  three 
to  six  times  as  great  as  that  among  the  more  fortunate  classes. 

Relations  to  Zymotic  Diseases. — In  investigating,  some  years  ago, 
the  nature,  causes,  and  prevention  of  puerperal  fever,*  I  prepared, 
*  Trans,  of  the  International  Med.  Congress,  Philadelphia,  1876. 


ggg  DISEASES  OF  CHILDBED. 

from  the  statistics  of  the  Health  Board  of  New  York  city,  tables  ex- 
tendino-  over  a  period  of  nine  years  to  answer  the  inquiry  as  to  whether 
tliere  was  any  relation  between  the  frequency  of  deaths  from  scarlatina, 
diphtheria,  and  erysipelas  and  those  from  metria.  Previous  to  their 
publication,  I  was  anticipated  in  my  deductions  by  a  paper  upon  the 
same  subject  by  Matthews  Duncan.*  Neither  Duncan  nor  myself 
found  any  such  relation  existing  between  the  statistical  frequency  of 
puerperal  fever  and  the  zymotic  diseases  mentioned.  There  was,  how- 
ever, nothing  in  our  investigations  to  invalidate  any  direct  testimony 
which  tends  to  show  that,  in  individual  cases,  a  real  connection  between 
puerperal  fever  and  the  zymotic  diseases  may  exist.  Indeed,  it  seems 
to  me  to  be  fairly  established  that  a  poison  may  be  conveyed  from 
patients  suffering  from  either  of  the  foregoing  morbid  processes  which 
may  be  absorbed  by  the  puerperal  woman,  and  may,  in  her,  give  rise  to 
an  infectious  fever  possessing  an  intense  degree  of  virulence. 

Prevention, — Doleris  formulates  the  indications  for  effective  pro- 
jihylaxis  as  follows :  1,  prevent  the  introduction  of  germs  (antisepsis 
before  confinement) ;  2,  paralyze  their  action  (antisepsis  after  confine- 
ment) ;  3,  shut  up  the  doors — veins,  lympluitics,  and  Fallopian  tubes 
(employment  of  means  which  promote  uterine  contraction). 

The  results  in  the  application  of  these  rules  are  best  shown  in  the 
modern  statistics  of  lying-in  hospitals.  The  records  of  the  Health 
Board  between  the  years  1868  to  1875,  inclusive,  showed  that  at  that 
time  nearly  one  sixth  of  the  deaths  from  metria  in  New  York  city  were 
contributed  by  the  hospitals.  To  cite  a  single  example :  In  the  year 
1873  there  were  449  births  in  Bellevue  Hospital ;  there  were  2")  ma- 
ternal deaths,  15  of  which  were  the  result  of  septic  infection.  The 
proportion  of  one  death  from  sepsis  to  thirty  cases  of  childbirth 
was  at  that  time  the  usual  one  in  the  maternities  of  tliis  country  and 
of  Europe,  reported  differences  being  rather  of  bookkeeping  than  of 
fact.  There  was  always,  likewise,  a  large  unreckoned  contingent  of 
patients  with  pelvic  inflammatory  troubles  which  ended  in  recovery. 
In  1874,  between  the  1st  of  January  and  the  11th  of  June,  of  lOG 
patients  confined,  31  died  of  puerperal  fever.  Similar  fatal  epidem- 
ics were,  at  that  time,  of  not  infrequent  occurrence  in  the  best  ap- 
pointed maternities. 

During  the  years  1885  to  1889,  inclusive,  837  Avomen  have  been 
confined  in  the  Emergency  Hospital,  and  there  have  been  10 
deaths,  i.  e.,  nearly  1  to  82.  A  glance  at  the  record  shows  that  these 
cases  are  the  best  illustrations  of  the  difficulties  with  which  the  institu- 
tion has  to  contend,  and  of  the  value  of  the  antiseptic  principle. 

*  On  the  Alleged  Occasional  Epidemic  Prevalence  of  Puerperal  Pyaemia,  or 
Puerperal  Fever  and  Erysipelas.  Edinburgh  Mod.  Journal,  March,  1876,  p.  774. 
Recent  observations  have  shown  that  morphologically  the  streptococci  of  erysipelas 
and  those  of  puerperal  fever  are  indistinguishable. 


PUERPERAL   FEVER.  ggT 

Thus,  there  were  five  deaths  from  eclampsia.  The  patients  were 
all  sent  to  the  hospital  after  the  convulsions  had  gained  full  headway. 

One  was  a  case  of  placenta  previa.  The  labor  had  been  lengthy 
and  the  htemorrhages  profuse  before  the  patient  was  admitted. 

One  was  a  case  of  Cesarean  section,  performed  on  account  of  the 
obliteration  of  the  cervix  and  vagina  by  cancer. 

A  patient  was  sent  to  the  Emergency  in  labor,  with  delirium  tre- 
mens.    She  died  twenty-four  hours  after  delivery. 

There  were  two  deaths  following  version  in  neglected  shoulder 
presentations.  Both  women  had  been  in  labor  several  days  previous  to 
admission.     The  children  were  dead,  and  decomposition  had  set  in. 

In  two  cases  the  women  had  been  respectively  two  and  one  half  and 
four  days  in  labor  when  admitted.  The  children  were  dead.  There 
was  a  stinking  discharge  and  commencing  decomposition  of  the  foetus. 

In  tAvo  cases  the  high-forceps  operation  had  been  performed  surrep- 
titiously by  unqualified  persons.  In  both  instances,  the  lower  uterine 
segment  was  ruptured,  and  death  speedily  followed. 

In  a  twin  pregnancy,  where  one  child  was  delivered  by  forceps  and 
the  second  by  version  after  a  long  labor,  death  occurred  from  sep- 
ticaemia. 

There  remains  one  other  case,  concerning  which  no  record  has  been 
preserved. 

Thus,  of  the  sixteen  deaths,  one,  or  possibly  two,  can  be  construed  as 
due  to  puerperal  fever. 

I  have  ventured  to  offer  these  particulars  because  there  is  no  pre- 
tense that  the  Emergency  is  a  model  for  imitation.  It  has  no  fans  for 
ventilation  ;  no  provision  for  a  rotation  of  wards.  It  is  intended  for 
the  homeless  class.  It  receives  constantly  women  with  high  temper- 
atures due  to  infection  before  their  entrance,  or  who  have  been  days  in 
labor,  or  who  have  been  subjected  to  unavailing  attempts  at  artificial 
delivery  by  outside  physicians.  It  therefore  furnishes  an  excellent  test 
of  the  value  of  modern  antiseptic  methods. 

Now,  the  regulations  by  which  these  results  have  been  obtained  are 
comparatively  simple.  The  patient,  on  her  entrance  into  the  hospital, 
receives  a  full  bath.  A  rectal  injection  is  given.  The  lower  abdomen, 
the  inner  surfaces  of  the  thighs,  the  pudenda,  and  the  anus  are 
scrubbed  with  soap  and  water,  then  washed  with  plain  water,  and 
finally  cleansed  with  a  1  :  1,000  solution  of  corrosive  sublimate.  The 
vagina  is  first  douched  with  soap  and  water,  and  then  with  a  1  :  5,000 
solution  of  corrosive  sublimate.  In  operative  cases  these  douches  are 
repeated  before  and  after  the  introduction  of  the  hand  or  instru- 
ments. The  Bellevue  Hospital  internes,  while  on  duty,  are  not  per- 
mitted to  visit  the  dead-house  or  the  erysipelas  pavilion.  They  are  not 
allowed  to  assist  at  surgical  operations,  nor  to  take  part  in  the  dressing 
of  wounds.    When  in  attendance  upon  a  case  of  labor,  both  interne  and 


ggg  DISEASES  OF  CHILDBED. 

nurse  wash  their  hands  and  forearms  with  soap  and  water,  with  pure 
water,  and  with  corrosive-sublimate  sokitiou  (1  :  1,000),  Before  an 
internal  examination  is  made,  the  hands  are  freshly  washed  with  the 
bichloride  solution.  Infrequent  examinations  are  recommended.  In- 
struments are  placed  in  a  2-per-cent  solution  of  carbolic  acid.  After 
they  have  been  used,  they  are  boiled  and  polished  for  future  service. 

The  Crede  method  of  expelling  the  placenta  is  employed.  Ergot 
is  given  to  secure  good  uterine  contractions.  In  all  cases  after  labor 
the  vagina  is  douched  with  the  bichloride  solution  (1  :  5,000).  In 
cases  of  protracted  labor,  of  high-forceps  operation,  of  version,  or  of 
any  manipulations  by  means  of  which  air  is  admitted  to  the  uterine 
cavity,  the  douche,  after  preliminary  vaginal  irrigation,  is  extended  to 
the  uterine  cavity.  The  external  parts  are  then  dusted  with  iodoform, 
and  are  covered  with  a  piece  of  gauze  freshly  wet  with  bichloride  solu- 
tion (1  :  5,000).  Outside  is  placed  a  pad  of  oakum.  The  dressing  is 
changed  once  in  six  hours,  at  which  time  the  genitals  are  scrupulously 
cleansed.     During  childbed  no  vaginal  douches  are  given. 

In  the  main,  the  plan  of  treatment  carried  out  is  tluit  introduced 
by  Garrigues  at  Charity  Hospital  five  years  ago.  Its  success  is  attested 
not  only  by  the  absence  of  deaths  due  to  septic  infection,  but  by  the 
morbidity  in  the  wards.  The  temperatures  rarely  rise  above  100^°, 
and,  as  a  rule,  do  not  reach  100°.  But  the  plan  of  treatment  presup- 
poses intelligent  instruments.  For  us  these  are  supplied,  on  the  one 
hand,  by  the  training-school  for  nurses  ;  on  the  other,  by  the  hospital 
interne,  who  enters  upon  his  duties  thoroughly  familiar  with  the  re- 
quirements of  surgical  cleanliness.  The  occasional  appearance  on  the 
scene  of  an  individual  who  uses  his  "  common  sense  " — i.  e.,  one  who 
does  not  believe  there  is  any  harm  in  witnessing  an  autopsy,  or  in  visit- 
ing a  companion  in  the  erysipelas  ward,  or  in  holding  the  pus  basin  in 
an  operation  for  pyo-thorax — is  almost  certainly  followed  by  tempera- 
ture elevations,  which  add  fresh  testimony  to  the  efficacy  of  a  rigid 
observance  of  antiseptic  regulations. 

It  is,  however,  to  be  acknowledged  that  there  is  by  no  means  una- 
nimity among  authorities  in  relation  to  certain  of  the  rules  prescribed. 
Thus,  the  pad  to  the  vulva  is  sneered  at,  by  many,  as  savoring  of  the 
heresy  that  the  air  can  become  the  source  of  contagion.  For  my  own 
part,  I  believe  an  antiseptic  dressing  and  pad  are  of  immense  service  in 
hospital  practice,  where  patients  are  aggregated  together,  as  a  means 
of  preventing  the  decomposition  of  the  lochia.  The  latter  is  inevitable 
upon  the  external  parts  when  the  ordinary  napkin  is  employed.  It 
seems  to  me  incontrovertible  that  the  air  does  thereby  become  contami- 
nated, and  it  is  doing  violence  to  the  evidence  to  deny  the  pernicious 
influence  of  a  germ-laden  atmosphere  upon  puerperal  wounds.  The 
argument  that  such  an  admission  has  a  tendency  to  weaken  the  per- 
sonal responsibility  of  the  physician  is  childish.     Aside  from  the  fact 


PUERPERAL  FEVER.  0g9 

that  science  is  based  upon  truth,  and  not  upon  teleological  considera- 
tions, the  belief  in  a  twofold  origin  of  puerperal  fever  simply  doubles 
his  responsibility.  To  be  sure,  Leopold*  found  that  of  427  patients 
in  the  Dresden  Maternity,  who  had  not  been  examined  or  treated  with 
corrosive  sublimate  previous  to  confinement,  only  7  had  a  rise  of  tem- 
perature, and  this  fact  taken  by  itself  would  seem  to  indicate  that 
direct  contact  alone  is  capable  of  producing  infection.  But  these 
patients  were  confined  under  favorable  sanitary  conditions.  Szabo,f 
on  the  contrary,  during  an  epidemic  of  fever  in  the  Pesth  Maternity, 
gave  orders  that  no  examinations  should  be  made.  Of  90  patients  con- 
fined under  these  conditions,  more  than  one  third  had  febrile  disturb- 
ances ;  and  two  of  the  patients,  upon  whom,  in  one  case,  sutures  and, 
in  the  other,  serres-fines  were  employed  for  perineal  laceration,  died. 
The  researches  of  Ott  J  and  Thomen  *  show  that  in  healthy  women 
the  bacteria  contained  in  the  lochia  are  found,  not  in  the  upper  por- 
tion of  the  vagina,  but  near  the  introitus,  which  would  certainly  indi- 
cate that  they  are  ordinarily  derived  from  external  sources.  At  any 
rate,  since  the  use  of  the  pad  at  the  Emergency  Hospital,  it  has  been 
possible  to  do  away  with  the  old-time  rotation  of  wards,  and  the  febrile 
temperatures,  which  once  were  so  marked  a  feature  of  the  winter 
months,  when  the  windows  were  closed,  are  now  no  longer  observable. 

The  subject  of  prophylactic  douches,  during  labor,  has  likewise  been 
one  of  endless  contentions.  In  private  practice  they  are  certainly 
needless.  Their  employment  at  the  Emergency  has  not,  however,  been 
the  result  of  theory,  but  has  been  the  outcome  of  the  condition  of  the 
patients  admitted,  most  of  them  having  been  examined  previously  by 
not  overfastidious  midwives  or  physicians. 

The  differences  which  divide  obstetrical  authorities  concerning  the 
ante-partum  douche  is  not  so  much  the  result  of  conflicting  experiences 
as  of  doctrinal  convictions.  Thus,  Barnes,  Ahlfeld,  Kaltenbach,  and 
others,  have  shown  that,  in  spite  of  every  pains  taken  to  exclude  con- 
tact-infection, temperature  elevations  will  occasionally  occur  in  child- 
bed. These  febrile  disturbances  they  regard  as  the  product  of  a 
materies  morli^  existent  in  the  genital  canal  prior  to  labor  ;  or,  to  use  a 
term  which  at  present  is  not  only  a  designation,  but  a  war-cry,  such 
cases  are  due  to  auto-infection.  It  is  a  matter  of  common  agreement 
that,  in  severe  cases  of  puerperal  infection,  the  utero-vaginal  canal 
swarms  with  bacterial  forms,  and  that,  of  these,  the  streptococcus  pyo- 
genes is  the  most  certain   accompaniment   of  specific   inflammatory 

*  Leopold,  Dritter  Beitrag  zur  Verhiitung  der  Kindbiltfiebers,  Arehiv  f.  Gyna- 
kologie,  vol.  xxxv,  p.  149. 

fSzABO,  Zur  Frageder  Selbstinfection,  Ibid.,  vol  xxxiv,  p.  153. 
t  Ott,  Zur  Bacteriologie  der  Lochien,  Ibid.,  vol.  xxxii. 

*  Thomen,  Bacteriologisehe  Untersuchungen  Normaler  Lochien,  etc.,  Ibid.,  vol. 
xxxvi,  p.  247. 

44 


^QQ  DISEASES  OF  CHILDBED. 

troubles.  When  convalescence  sets  in,  the  coccus  forms  correspond- 
ino-ly  disappear  from  the  lochial  discharges.  But  the  vagina  at  all 
times  contains  a  varied  assortment  of  bacterial  germs.  Nothing  would 
seem  simpler,  therefore,  than  the  deduction  that  these  germs  are  al- 
ways potential  sources  of  evil.  As  a  logical  outcome  of  this  doctrine, 
its  extreme  supporters  insist  upon  a  complete  sterilization  of  the  vagina 
in  every  case  of  labor  as  an  ordinary  prophylactic  precaution.  Thus, 
Steffeck  *  advises  the  irrigation  of  the  vagina  during  labor,  at  two-hour 
intervals,  with  a  litre  of  corrosive-sublimate  solution.  To  increase  its 
efficiency  he  introduces  two  fingers  into  the  vagina  to  scrub,  during 
the  douche,  first  the  vaginal  mucous  membrane  and  then  the  interior 
of  the  cervix.  Doderlein  f  recommends  that  the  vagina  be  first  rubbed 
thoroughly  with  a  preparation  of  creolin  and  molliu,  and  then  be  irri- 
gated, for  ten  minutes,  with  a  creolin  solution. 

Fortunately,  these  suggestions,  which  would  have  a  tendency  to 
handicap  fatally  the  employment  of  antiseptic  measures  in  midwifery, 
have  not  been  received  with  much  favor,  even  by  the  partisans  of  the 
doctrine  of  auto-infection.  But,  on  the  other  hand,  the  pathogenic 
character  of  the  germs  contained  in  the  vagina  has  been  disputed. 
Thus,  Artemieff  I  says  that  "  the  lochia  of  perfectly  healthy  puerperal 
women  contains  no  micro-organisms."  Bokelmann  **  maintains  that  a 
healthy,  normal  puerperal  woman  is  a  priori  to  be  regarded  as  aseptic. 
He  objects  to  attempted  sterilization  on  the  ground  that  the  measures 
emjDloyed  mechanically  delay  the  progress  of  labor  by  the  removal  of 
the  normal  vaginal  mucus,  and  at  the  same  time  render  more  vulner- 
able the  tears,  the  excoriations,  and  the  surfaces  from  which  the  epi- 
thelium has  been  detached. 

Kaltenbach,||  althougli  a  defender  of  auto-infection,  states  that  in 
easy,  rapid,  births  the  germs  are  carried  away  by  blood,  amniotic  fluid, 
and  the  passage  of  the  child ;  but  in  tardy  labors,  or  in  case  of  the 
premature  rupture  of  the  membranes,  the  entrance  of  germs  into  the 
uterine  cavity  is  facilitated,  and  many  may  remain  in  the  uterus  and 
become  a  source  of  danger.  Diseases  resulting  from  auto-infection  are 
lighter  in  character  than  those  due  to  inoculation.  Infection  is  first 
preceded  by  putrefaction.  A  complete  destruction  of  germs  is  unne- 
cessary ;  those  that  remain  in  ittero  are  rendered  harmless  by  ordinary 
injections.     Even  Winter  states  that,  in  the  present  condition  of  our 

*  Steffeck,  Ueber  Disinfection  des  weiblichen  Genital-canals,  Zcitschrift  flir 
Geburtskunde,  vol.  xv,  p.  395. 

f  Doderlein  und  GCnther,  Disinfection  des  Geburts-canals,  Archiv  fur 
Gynakologie,  vol.  xxxiv,  p.  111. 

X  Artemieff,  Micro  und  bacterioscopische  Untersuchungen  der  Lochien,  Zeit- 
schrift  f.  Geburtskunde,  vol.  xvii,  p.  174. 

*  Bokelmann,  Die  Antisepsis  wahrend  der  Geburt,  Ibid.,  vol.  xvii,  p.  341. 
II  Kaltexbach,  Archiv  f.  Gynakologie,  vol.  nxxv,  p.  489. 


PUERPERAL  FEVER.  qqi 

bacteriological  investigations,  it  is  not  right  to  carry  out  the  attempts 
at  complete  sterilization  recommended  by  Steffeck  and  Doderlein. 

In  private  practice,  under  ordinary  conditions,  the  presence  in  the 
vagina  of  infectious  forms  of  bacteria  is  hardly  conceivable,  except  in 
cases  where  they  have  been  directly  imported  by  the  finger  or  by  in- 
struments. This  statement  is  based  both  upon  microscopic  investiga- 
tions and  upon  clinical  experience.  So  far,  it  has  not  been  possible,  m 
the  rare  instances  where  beaded  cocci  have  been  found  in  the  vaginal 
secretions,  ante-partum,  to  obtain  by  pure  cultures  a  product  capable 
of  giving  rise  to  spreading  inflammations ;  and  in  rural  districts,  even 
with  not  overcleanly  surroundings,  immunity  from  infectious  puer- 
peral diseases  is  the  rule.  That,  however,  the  vagina,  which  is  not  a 
hermetically  closed  tube,  should,  like  the  atmosphere,  contain  germs 
capable  of  producing  putrefaction  is  hardly  doubtful.  Under  healtliy 
conditions  the  uterine  cavity,  on  the  contrary,  contains  no  bacterial 
forms,  and  it  is  not  invaded  by  them  in  normal  parturition,  a  fact  at- 
tributed to  their  feeble  migratory  power  and  to  the  downward  current 
of  the  secretions.  Con<litions  which  favor  the  passage  of  germs  from 
the  vagina  into  the  uterus  are  relaxation  of  the  uterine  walls,  and  mem- 
branes hanging  from  the  cervix.  The  increased  morbidity  which  ac- 
companied the  once  popular  vaginal  douche  in  childbed  was  doubtless 
owing  to  the  circumstance  that,  while  of  feeble  disinfectant  power,  tlie 
injected  stream  furnished  in  many  instances  a  direct  highv/ay  to  the 
uterine  cavity.  True  midwifery  antisej^sis  consists  not  so  much  in 
douching  as  in  furthering  physiological  processes.  Under  normal  cir- 
cumstances, a  proper  handling  of  the  patient  during  labor  will  effect 
more  in  the  way  of  prophylaxis  than  the  most  effective  germ-destroy- 
ing agents.  When,  however,  hands  or  instruments  are  introduced  into 
the  uterine  cavity,  the  case  is  different.  It  would  be  hardihood  then 
not  to  precede  the  operative  measure  by  thorough  vaginal  disinfection. 

In  private  practice  too  great  pains  can  not  be  taken  with  the  sani- 
tary surroundings.  The  sheets  and  the  napkin  or  pad  to  the  vulva 
should  be  matters  of  personal  supervision.  Slovenly  laundry  work  is 
dangerous.  I  prefer  the  pad  because  it  is  destroyed  after  having  been 
once  in  use.  The  employment  of  napkins  which  have  been  left  in  a 
pail  until  putrefaction  is  well  advanced,  and  are  then  soaked  and  dried 
before  the  fire  by  the  monthly  nurse,  is  a  familiar  procedure,  and  a 
direct  temptation  of  Providence. 

In  city  homes  close  inquiries  should  be  made  in  reference  to  the 
condition  of  closets  and  sewer  connections.  My  attention  was  first 
drawn  to  the  similarity  of  typhoid  and  septic  fever  in  puerperal  cases 
by  a  patient  sent  to  the  hospital  in  a  moribund  condition.  Her  child 
had  been  removed  by  a  high-forceps  operation,  and  the  cervix  was 
badly  lacerated.  I  regarded  her  symptoms  as  typical  of  puerperal  fever, 
but  the  post-mortem  examination  showed  a  perfectly  healthy  condition 


692 


DISEASES  OF  CHILDBED. 


of  the  pelvic  organs  and  the  characteristic  intestinal  lesions  of  typhoid. 
Durino-  the  years  of  low  water  supply  in  New  York,  I  have  many  times 
heen  called  to  see  patients  with  high  fever  who  were  undergoing  the 
customary  douchings,  while,  in  the  adjoining  closet,  the  basin  into  which 
the  dejecta  of  the  patient  were  being  thrown  was  washed  out,  once  or 
twice  daily,  by  a  pitcher  of  water  poured  into  the  basin  by  hand.  The 
dano-ers  of  defective  house  sanitation  have  been  ably  presented  by  my 
friend  Professor  Playfair,  and  I  find  it  difficult  to  understand  the 
attitude  of  those  who  find  no  harm  in  the  condition  I  have  described 
because,  they  say,  it  does  not  affect  the  drinking  water. 

A  physician  from  the  country  called  upon  me  to  consult  me  about 
an  epidemic  of  puerperal  fever  in  his  practice.  I  asked  him  many 
questions,  but  received  no  enlightening  answer  as  to  the  cause.  The 
physician  was  intelligent,  and  had  seemingly  taken  every  needful  pre- 
caution. As  he  was  about  to  leave  me  I  inquired  whether  there  was 
any  diphtheria  in  his  neighborhood.  He  answered,  he  had  "  lots  of 
it,"  and  seemed  surprised  that  I  should  connect  the  diphtheria  and 
puerperal  fever  together.  It  seems  to  me  a  thoroughly  false  idea  that 
a  physician  can  attend  erysipelas,  diphtheria,  and  scarlet  fever,  and  at 
the  same  time  pursue  his  midwifery  practice  with  impunity,  provided 
he  makes  free  use  of  corrosive  sublimate  and  carbolic  acid.  Indeed,  I 
am  almost  disposed  to  regard  as  a  special  form  of  blindness  the  preva- 
lent faith  that  parturient  and  puerperal  women  can  only  be  infected 
by  the  finger  and  through  the  vagina. 

Treatment. — When  the  germs  characteristic  of  septic  infection  have 
once  entered  the  tissues  they  are  beyond  the  reach  of  the  physician. 
Except,  however,  in  cases  of  acute  septicaemia,  where  the  quantity  of 
poison  introduced  into  the  circulation  at  the  outset  is  excessive,  the 
patient  rallies  from  the  immediate  shock,  and,  provided  no  fresh  pyro- 
genic  material  finds  its  way  into  the  system,  recovery  is  to  be  antici- 
pated. The  indications  for  treatment  are,  therefore,  to  neutralize  the 
puerperal  poison  at  the  point  of  production,  in  order  to  prevent  its 
causing  further  mischief,  and  to  adopt  measures  caknilatod  to  enable 
the  patient  to  tolerate  its  presence,  when  once  absorbed,  until  it  is 
either  eliminated  or  loses  its  harmful  properties. 

Toward  the  fulfillment  of  the  first  indication  it  is  to  be  recom- 
mended that,  in  every  case  of  fever  of  puerperal  origin,  the  vagina  be 
cleansed  with  a  2  to  3  per  cent  solution  of  carbolic  acid  or  corrosive 
sublimate  (1  :  3,000)  every  four  to  six  hours.  The  douche  in  itself  is 
absolutely  harmless.  To  avoid  carbolic  or  corrosive-sublimate  poison- 
ing, it  is,  however,  necessary  to  make  sure  that  no  portion  of  the  in- 
jected fluid  be  retained  in  the  vagina.  In  most  cases  the  infection 
starts  from  the  wounds  of  the  vagina  and  of  the  cervix.  Then,  too, 
the  tendency  of  the  secretions  to  stagnate  in  the  vaginal  cul-de-sac, 
bathing  as  they  do  the  cervical  portion,  is  a  prolific  source  of  septic 


PUERPERAL   FEVER.  693 

trouble.  In  all  but  the  mildest  cases  the  vaginal  orifice  should  be  ex- 
amined with  reference  to  the  existence  of  puerperal  ulcers.  All  ne- 
crotic patches  should  be  touched  with  hydrochloric  acid,  with  a  10-per- 
cent solution  of  carbolic  acid,  with  iodoform,  or,  what  I  personally 
prefer,  a  mixture  composed  of  equal  parts  of  the  solution  of  the  per- 
sulphate of  iron  and  the  compound  tincture  of  iodine.  The  latter 
acts  as  a  powerful  antiseptic,  while  the  former,  by  corrugating  the 
tissues,  closes  the  lymphatics  and  shuts  up  the  portals  through  which 
the  septic  germs  penetrate  into  the  system. 

Intra-uteriue  injections,  in  spite  of  the  prevalent  belief  that  they 
constitute  the  rational  treatment  for  puerperal  fever,  should  be  resorted 
to  with  extreme  circumspection,  as  they  interfere  with  the  localizing 
processes  by  which  most  of  the  pelvic  inflammations  become  self- 
limited  ;  they  help  to  extend  the  morbid  condition  of  the  uterine 
cavity  to  the  tubes,  and,  if  continued  long  enough,  they  paralyze  the 
uterine  walls,  so  that  after  death  the  fundus  is  found  to  contain  a  dirty 
pool  alive  Avith  bacteria. 

Eunge  reports  an  epidemic  of  puerperal  fever  in  Gusserrow's  clinic 
brought  about  by  the  employment  of  intra-uterine  irrigations,  during 
which  the  mortality  rose  to  3-8  per  cent.  With  the  abolition  of  the 
irrigations  the  mortality  sank  to  -39  per  cent.  In  1880  Fischel  intro- 
duced the  so-called  permanent  irrigations  into  the  Prague  Maternity. 
Of  880  patients,  9  died  of  sepsis.  The  irrigations  were  then  prohibited. 
The  following  year,  of  933  patients,  only  3  died  from  the  same  cause, 
and  in  1882,  of  521  patients,  there  were  no  deaths  from  sepsis.  Fehl- 
ing,  who  limited  the  use  of  intra-uterine  injections  to  special  moment- 
ary indications,  reported,  in  1880,  415  confinements  without  a  single 
death.  Unless  the  infection  proceeds  from  the  uterine  cavity,  they  are 
unnecessary.  Nor  must  it  be  forgotten  that  puerperal  women  are  not 
exempt  from  febrile  disorders  other  than  those  due  to  sepsis.  Before 
the  douche  is  used  the  breasts  should  be  examined.  The  douche  can 
help  but  little  in  acute  and  suppurative  inflammations  awakened  by 
labor,  and  in  patients  who  have  had  chronic  unilateral  salpingitis  ante- 
dating pregnancy.  In  cases  of  true  puerperal  infection,  due  to  the 
penetrative  form  of  micrococci  and  associated  with  spreading  forms  of 
inflammation,  the  use  of  the  douche  is  probably  idle,  and  no  more  effect- 
ive than  washing  the  surface  of  the  skin  in  an  external  erysipelatous 
process ;  and  yet  it  is  common  to  persist  in  the  practice  in  spite  of 
negative  results. 

The  employment  of  the  douche  in  fevers  resulting  from  the  ab- 
sorption of  toxine  due  to  the  putrefaction  of  clots,  membranes,  and 
bits  of  placenta  within  the  uterus,  on  the  other  hand,  is  followed  by 
immediate  favorable  results,  and  by  the  prompt  disappearance  of 
danger.  But  it  is  to  be  remembered  that  this  is  a  clumsy  attempt  to 
remedy  the  results  of  past  remissness. 


694 


DISEASES   OF  CHILDBED. 


The  indications  for  the  douche  as  popularly  employed  are  especially 
vao-ue.  One  man  is  governed  by  the  odor  of  the  lochia,  but  the  odor  in 
ordinary  catarrhal  endometritis  is  offensive,  and  yet  all  such  cases  re- 
cover unless  aggravated  by  the  douche.  Again,  as  Bumm  has  pointed 
out,  the  products  of  tissue  disintegration  may  be  virulently  poisonous 
and  yet  the  odor  may  be  absent.  Others,  again,  use  the  douche  when 
the  temperature  reaches  102°.  But  tlie  temperature-guide  leaves  out 
of  sio-ht  the  multitude  of  temporary  temperature  elevations  due  to 
trivial  local  troubles,  to  psychical  causes,  and  to  malaria. 

The  operation  of  cleansing  the  uterus  should  be  conducted  with  the 
most  scrupulous  care.  The  syringe  employed  should  produce  a  con- 
tinuous and  not  an  interrupted  stream,  and  all  air  should  be  expelled 
from  the  pipe.  The  tube  to  be  passed  through  the  cervix  should  be  of 
glass,  of  the  size  of  the  little  finger,  and  bent  somewhat  to  conform  to 
the  pelvic  curve.  Tlie  vagina  should  first  be  subjected  to  a  tliorough 
disinfection,  by  way  of  precaution  against  conveying  septic  materials 
into  the  uterus.  The  introduction  of  the  tube  should  be  made  with 
the  guidance  of  two  fingers  passed  through  tlie  external  os.  But 
slight  force  is  requisite  to  reach  the  internal  os.  It  is  neither  neces- 
sary nor  desirable  to  push  the  tube  to  the  fundus.  The  fluid  injected 
should  be  tepid,  and,  if  carbolic  acid  is  used,  of  the  strength  of  two  or 
three  drachms  to  the  pint;  if  corrosive  sublimate  is  em])h)yod,  the 
strength  should  not  exceed  1  :  3,000.  It  sliould  be  introduced  very 
slowly,  and  pains  should  be  taken  to  insure  its  unimpeded  escape, 
which  can  usually  be  accomplished  by  pressing  the  anterior  wall  of  the 
cervix  forward  by  means  of  the  glass  tube. 

I  would  strongly  recommend,  after  the  douche,  the  introduction  of 
the  iodoform  bacillus  of  Spaeth  and  Braun.  The  formula  recom- 
mended consists  of — 

I^   lodof ormi 20  grammes. 

Gummi  Arabici, 

Olyceri-nae, 

Amyli  puri aa  2  grammes. 

Ft.  Bacilli No.  iij. 

If  the  fever  persists,  it  is  sometimes  desirable  to  follow  tlie  advice  of 
Doleris  and  of  Braun  von  Fernwald,  and  explore  tlie  uterine  cavity 
with  the  curette  for  retained  bits  of  tissue.  But  it  is  time  to  stop 
treatment  at  this  point.  There  is  nothing  more  fatuous  than  the  ex- 
pectation of  curing  the  patient  by  redoubling  the  vigor  of  the  treat- 
ment. 

Of  the  symptoms,  the  first  in  order  which  calls  for  treatment  is 
usually  the  peritoneal  pain.  It  is,  as  we  have  seen,  commonly  of  a 
lancinating  character,  and  is  associated  with  hurried  breathing  and 
extreme  frequency  of  the  pulse.  So  soon  as  the  pain  is  once  fairly 
under  control,  the  violence  of  the  onset  begins  to  abate.     It  should  be 


PUERPERAL  FEVER.  595 

met,  therefore,  by  the  hypodermic  injection  of  from  one  sixth  to  one 
third  grain  of  morphia  in  soh;tion.  The  anodyne  action  should  be 
maintained  by  doses  administered  by  the  mouth  in  quantities  and  at 
intervals  suited  to  the  severity  of  the  case.  The  most  important  object 
to  be  secured  is  freedom  from  spontaneous  pain.  It  is,  moreover,  good 
practice  to  push  the  opiate  until  pain  elicited  by  pressure  is  likewise 
controlled,  provided  it  can  be  accomplished  without  producing  nar- 
cosis. In  susceptible  patients  and  in  localized  inflammations  the  quan- 
tity required  may  not  be  very  great,  while,  in  acute  general  peritonitis, 
the  tolerance  of  the  drug  exhibited  by  puerperal  women  is  sometimes 
extraordinary.  Thus,  a  patient  of  Alonzo  Clark  took  the  equivalent  of 
934  grains  of  opium  in  four  days ;  a  patient  of  Fordyce  Barker,  13,909 
drops  of  Magendie's  solution  in  eleven  days ;  and  one  of  my  own,  at 
the  Maternity,  the  equivalent  of  over  1,700  grains  of  opium  in  seven 
days.*  In  this  latter  instance  the  patient  was  to  all  appearance  mori- 
bund when  the  treatment  was  begun.  Thus,  the  features  were  pinched, 
the  face  was  drawn,  the  pupils  were  dilated,  the  finger-tips  were  blue 
and  cold,  the  respirations  were  rapid,  and  the  pulse  was  scarcely  per- 
ceptible. In  this  condition  the  large  doses  of  opium  did  not  produce 
narcosis,  but  were  followed  by  restoration  of  the  circulation,  by  normal 
breathing,  and  by  the  disappearance  of  the  symptoms  of  shock.  Any 
attempt  to  relax  the  treatment  was  at  once  succeeded  by  a  recurrence 
of  the  alarming  symptoms.  At  the  expiration  of  the  disease,  the  opium 
was  discontinued  abruptly  without  detriment  to  the  patient. 

In  contrast  to  cases  of  acute  peritonitis,  an  extreme  susceptibility  to 
opium  is  often  observed  in  the  pyasmic  variety.  Here  opiates  seem  to 
me  rarely  to  do  good.  They  do  not  hinder  the  migrations  of  the  round 
bacteria,  there  is  rarely  pain  to  relieve,  and  I  have  sometimes  thought 
that  their  administration  was  simply  the  addition  of  a  second  poison 
to  the  one  which  already  was  overwhelming  the  nervous  system. 

In  pelvic  peritonitis,  in  the  course  of  forty-eight  hours,  plastic  exu- 
dation is  thrown  out  and  the  pain  to  a  great  extent  subsides.  From 
this  time  very  moderate  doses  of  opium,  as  a  rule,  are  needed  to  make 
the  patient  comfortable. 

In  France,  leeches  applied  to  the  abdomen  are  much  used  as  a 
means  of  relieving  peritoneal  sensitiveness.  That  they  do  this  is  be- 
yond question.  Their  disuse  in  this  country  is  due  probably  more  to 
popular  prejudice  than  to  their  inefficacy. 

In  the  beginning  of  an  attack  a  turpentine  stupe  to  the  abdomen  is 
a  source  of  comfort  to  many  women,  while  the  sharp  counter-irritation 
exercises  possibly  a  favorable  influence  upon  the  course  of  the  disease. 
At  a  later  period  I  commonly  employ  flannels  wrung  out  in  water  and 
covered  with  oil-silk  to  prevent  speedy  evaporation.     It  is  an  old  ex- 

*The  details  of  this  ease  have  been  reported  in  the  Am.  Jour,  of  Obst.,  Oct., 
1880,  p.  864,  by  Dr.  F.  M.  Welles,  who  conducted  the  administration  of  the  opium. 


QQQ  DISEASES  OP  CHILDBED. 

perience  that,  in  the  beginning  of  a  puerperal  fever,  the  provocation  of 
loose  stools  by  purgatives  is  frequently  followed  by  a  fall  in  the  tem- 
perature and  a  great  improvement  in  the  patient's  condition.  The  re- 
sult however,  is  far  from  uniform,  as  in  other  cases  these  artificial 
diarrhoeas  have  a  tendency  to  aggravate  the  peritoneal  symptoms. 
Owino-  to  this  uncertainty  in  their  action,  purgative  remedies  should  be 
administered  with  caution,  not  from  any  tlieory  as  to  their  eliminative 
powers,  but  because  of  the  ascertained  existence  of  fecal  accumulation. 
In  pelvic  inflammations,  castor  oil  in  two-  or  three-tablespoonf  ul  doses,  or 
five  to  ten  grains  of  calomel  rubbed  up  with  twenty  grains  of  bicarbon- 
ate of  sodium,  as  recommended  by  Barker,  may  be  given  when  thus 
indicated.  After  the  bowels  have  once  been  freed,  however,  the  pur- 
gative should  not  be  repeated.  In  cases  of  intense  local  inflammation 
and  in  general  peritonitis,  enemata  should  alone  be  employed  for  the 
removal  of  constipation. 

Every  increase  of  body  heat  is  associated  with  rapid  tissue  waste, 
with  enfeebled  heart-action^  and  with  exhaustion  of  the  nerve-centers. 
Since  the  modern  recognition  of  the  deleterious  effects  of  high  tem- 
peratures per  se,  antipyretic  remedies  in  place  of  the  old-time  cardiac 
sedatives  have  come  to  play  the  leading  I'ole  in  the  treatment  of  fevers. 

Of  internal  antipyretic  agents,  quiuia  enjoys  a  deservedly  liigli  re- 
pute. In  the  remitting  forms  of  fever  it  may  be  administered  in  five- 
grain  doses,  at  intervals  of  four  to  six  hours.  Given  thus  in  medium 
doses,  it  moderates  the  fever,  diminishes  the  sweating,  and  in  most 
patients  lessens  gastric  and  intestinal  disturbances.  In  continued 
fevers  it  should,  on  the  contrary,  be  given  in  a  single  dose  large  enough 
to  procure  a  distinct  remission.  By  making  a  break  in  the  febrile 
symptoms,  if  only  of  a  few  hours'  duration,  a  retardation  of  the  de- 
structive processes  is  accomplished.  At  the  first  administration,  twenty 
to  thirty  grains  may  be  given.  In  favorable  cases  the  temperature 
falls  in  the  course  of  a  few  hours  below  101°.  When  the  hiijli  tem- 
perature  is  only  temporarily  held  in  check,  at  the  end  of  twenty-four 
liours,  if  all  symptoms  of  cinchonism  have  disappeared,  the  same  dose 
should  be  repeated.  If  the  doses  mentioned,  given  in  the  manner  pre- 
scribed, produce  no  perceptible  effect  upon  the  fever,  their  continuance 
may  be  regarded  as  unnecessary. 

C.  Braun  and  Richter  speak  favorably  of  the  action  of  salicylate  of 
sodium.*  It  possesses  antipyretic  properties,  though  in  a  less  degree 
than  quinia.  It  is,  however,  rapidly  absorbed,  circulates  through  all 
the  parenchymatous  organs,  and  finally  is  discharged  unchanged  in  the 
urine.  It  is  said  by  Binz,  in  small  doses,  to  hinder  the  action  of  the 
disease-producing  ferments,  while  it  leaves  untouched  the  normal  fer- 
ments of  the  organism.     It  is  of  special  service  where  quinia  is  not 

*  Richter,  Ueber  intrauterine  Injectionen,  etc.,  Zeitschr,  fur  Geburtsk.  und 
Gynaek.,  Bd.  ii,  Heft  1,  p.  146. 


PUERPERAL  FEVER.  597 

well  tolerated,  or  when  given  fifteen  to  twenty  grains  at  a  time,  every 
four  to  six  hours,  as  an  adjuvant  to  large  single  doses  of  quinia.  The 
remedy  should  be  continued  until  all  traces  of  febrile  disturbance  have 
disappeared. 

A  more  powerful  remedy  than  salicylic  acid,  where  quinia  has 
failed,  is  the  Warburg's  tincture.  Some  patients  find,  however,  that 
it  is  somewhat  difficult  to  retain  upon  the  stomach. 

Antipyrine,  antifebrin,  or  phenacetin,  given  in  conjunction  with 
quinia,  are  usually  efficacious  in  producing  temporary  reductions  of 
temperature,  and  are  in  the  rule  well  borne.  Their  administration, 
however,  calls  for  watchfulness,  and  their  employment  should  be  sus- 
pended in  case  they  are  found  to  impair  the  quality  and  force  of  tlie 
pulse. 

Braun  recommends  in  severe  cases,  where  quinia  alone  is  without 
effect,  to  give  in  addition  from  twelve  to  twenty-four  grains  of  digi- 
talis in  infusion,  ^jer  diem,  until  its  specific  action  is  produced.  Unlike 
veratrum,  digitalis  effects  a  permanent  slowing  of  the  heart.  By  pro- 
longing the  cardiac  diastole  and  contracting  the  arterioles,  it  allows  the 
left  ventricle  to  fill,  restores  the  arterial  tension,  diminishes  correspond- 
ingly the  intravenous  pressure,  and  promotes  absorption.  Its  tend- 
ency to  produce  gastric  disturbances  and  the  distrust  felt  as  to  its  safety 
have  prevented  its  becoming  popular  in  practice. 

Alcohol  as  an  adjuvant  to  treatment  is  indicated  in  all  cases, 
whether  quinia  or  salicylic  acid  or  veratrum  be  simultaneously  em- 
ployed. It  stimulates  and  sustains  the  heart,  it  retards  tissue-waste, 
and  is  in  itself  an  antipyretic  of  no  mean  value.  Usually  I  give  it  in 
conjunction  with  quinia,  one  or  two  teaspoonfuls  hourly,  of  eitlier 
whisky,  rum,  or  brandy,  in  accordance  with  the  recommendation  of 
Breisky.* 

The  antipyretic  action  of  drugs  is  probably  due  for  the  most  part  to 
some  direct  influence  they  exert  upon  the  oxygenation  of  the  tissues. 
Of  course,  the  less  the  fire  the  less  the  heat.  It  is  well,  however,  to  sup- 
port their  internal  administration  by  the  external  employment  of  cold. 
Cold  owes  its  effect  in  fevers  partly  to  the  abstraction  of  heat  from  the 
body-surface,  and,  in  a  still  more  important  degree,  to  the  impression 
which  it  produces  upon  the  nervous  system.  In  healthy  persons  the 
action  of  cold  is  to  increase  the  consumption  of  oxygen  and  the  pro- 
duction of  carbonic  acid.  The  additional  heat  thus  generated  renders 
it  possible  to  sustain  the  vicissitudes  of  climate.  In  fevers  the  primary 
effect  of  cold  is  similar  in  character.  Its  main  therapeutical  action  is 
derived  from  its  secondary  influence  upon  the  nerve-center  which  regu- 
lates the  body-heat.  If  the  cold  employed  be  sufficiently  intense  or 
sufficiently  prolonged,  there  follows,  not  always  immediately,  but  in  the 
course  of  an  hour  or  two,  a  marked  lowering  of  the  temperature,  which 
*  Ueber  Alcohol  unci  Chininbehandlung,  Bern,  1875. 


g^g  DISEASES  OF  CHILDBED. 

can  only  be  accounted  for  by  assuming  an  indirect  influence  exerted 
through  the  sympathetic  nerve  and  the  medulla  oblongata.  This  pecul- 
iarity renders  the  external  application  of  cold  a  most  valuable  addition 
to  the  therapeutical  resources  available  in  fevers. 

In  cases  of  moderate  severity  frequently  sponging  the  patient  with 
cold  water  will  be  found  to  be  a  grateful  practice.  An  ice-cap  to  the 
head,  where  the  blood  lies  near  the  surface,  will  often  affect  the  entire 
temperature  of  the  body.  From  immemorial  times  it  has  been  em- 
ployed to  control  delirium  and  promote  sleep.  An  ice-bag  placed  over 
the  inguinal  region  is  locally  beneficial  to  deep-seated  pelvic  inflamma- 
tions, and,  according  to  Braun,  is  capable  of  effecting  a  rapid  fall  of 
temperature.     Ice-cold  drinks  should  be  freely  allowed. 

In  fevers  of  great  violence,  the  systematic  application  of  cold,  by 
means  of  baths  or  the  wet  pack,  is  capable  in  some  cases  of  rendering 
important  service.  The  temperature  of  the  bath  should  range  from 
70°  to  80°.  Its  duration  should  not  exceed  ten  minutes.  The  patient 
should,  when  removed  to  the  bed,  be  wrapped  in  a  sheet  without  dry- 
ing, and  should  be  comfortably  covered.  In  employing  the  wet  pack 
two  beds  should  be  placed  side  by  side.  The  body  and  thighs  of  the 
patient  should  be  wrapped  in  a  sheet  wrung  out  in  cold  water,  and  be 
allowed  to  remain  in  the  pack  from  ten  to  twenty  minutes.  As  the 
sheet  becomes  heated  the  patient  should  be  placed  in  a  fresh  one  upon 
the  second  bed,  and  the  transfers  should  be  continued  until  the  desired 
fall  of  temperature  is  effected.  Braun  chiims  that  four  packs  are 
equivalent  in  action  to  one  full  batli. 

In  some  instances  it  must  be  admitted  that  the  full  bath  is  followed, 
in  spite  of  hot  bottles  to  the  feet  and  the  administration  of  stimulants, 
by  such  a  degree  of  depression  and  impairment  of  cardiac  force,  as 
shown  by  the  persistent  coldness  of  the  extremities,  that  it  has  been 
necessary  to  discontinue  it.  Ou  the  other  hand,  I  can  look  back 
upon  cases,  apparently  so  desperate  that  the  condition  of  the  patients 
was  looked  upon  as  hopeless,  where  they  proved  the  means  of  saving 
life  as  by  a  miracle.  Of  course,  the  difference  depends  upon  whether 
the  high  temperature  is  the  sole  cause  of  the  alarming  symptoms,  or 
whether  the  latter  are,  in  part,  due  to  blood-dissolution  and  secondary 
changes  in  the  parenchymatous  organs. 

The  use  of  the  coil  in  fever,  whether  of  rubber  or  of  metal  tubing, 
\^y^^  can  highly  recommend.  Either  the  night-dress  or  a  towel  should  be 
placed  between  the  coil  and  the  skin.  A  current  of  cold  water  passing 
through  the  tube  rapidly  abstracts  the  surface  heat,  and  is  usually 
grateful  to  the  patient.  The  lowering  of  the  temperature  by  this 
means  is  much  slower  than  by  cold  affusions.  Disturbance  of  the 
patient  is,  however,  avoided,  and  the  method,  so  far  as  I  have  tried  it, 
has  been  free  from  the  objections  incident  to  the  direct  application  of 
water  to  the  skin. 


PUERPERAL  FEVER. 


699 


It  is  hardly  necessary  to  state  that  in  puerperal,  as  in  other  fevers, 
the  patient's  strength  requires  to  be  sustained  and  the  waste  of  tissue 
to  be  repaired,  as  far  as  possible,  by  the  regulated  administration  of 
liquid  food,  as  milk  and  beef-tea,  in  such  quantities  as  can  be  borne  by 
the  stomach.  Probably  in  the  future  laparotomy  is  destined  to  play  a 
prominent  role  in  the  treatment  of  puerperal  peritonitis.  Price  has  re- 
ported a  number  of  successes  which  recovered  after  early  operation 
followed  by  irrigation  and  drainage.  The  favorable  results  are  to  be 
expected,  he  states,  when  peritonitis  is  the  result  of  localized  disease,  as 
in  pus  collections  or  gangrenous  conditions  of  the  tubes  and  ovaries. 
The  idea  of  accomplishing  good  by  washing  out  the  peritonjeum  in 
lymphatic  peritonitis  is  chimerical.  The  peritonitis  is  only  a  single 
symptom  of  a  general  systemic  poisoning.  The  obstacle  to  popular- 
izing laparotomy  as  a  resource  in  the  treatment  of  puerperal  fever  has, 
so  far,  been  the  difficulty  of  differentiating  the  cases.  Thus,  Baldy 
states,  "  If  there  is  pus  in  the  tube  it  is  easy  to  settle  the  question." 
"  In  the  vast  majority  of  cases,"  he  adds,  "  in  which  I  have  been  asked 
to  decide  for  or  against  the  operation,  I  have  advised  waiting,  and  all 
these  cases  have  recovered."  And  again,  "  The  great  question  is  to  de- 
cide whether  pus  be  present  or  not,  and  it  requires  caution,  or  we  shall 
be  led  into  many  operations  which  will  be  unnecessary."  * 

In  the  treatment  of  encysted  peritoneal  effusions,  and  in  inflam- 
matory exudations  into  the  pelvic  and  adjacent  cellular  tissue,  after 
the  acute  symptoms  have  subsided  the  attention  should  be  directed  to 
the  afternoon  fever  and  to  promoting  the  assimilation  of  food.  So 
soon  as  the  sweating  and  fever  are  checked,  the  absorption  of  the 
})lastic  materials  begins.  The  most  important  agents  for  accomplish- 
ing this  object  are  quinia,  in  moderate  doses,  combined  with  some 
form  of  alcohol  and  with  tepid  sponging.  Deep-seated  pain  in  the 
iliac  region  is  best  relieved  by  a  large  blister  upon  the  side  over  the 
point  where  the  tenderness  is  felt.  Prolonged  rest  in  bed  should  be 
enjoined.  Even  after  convalescence  is  well  advanced,  so  long  as  the 
exudation  remains  unabsorbed,  the  resumption  of  household  duties  is 
pretty  certain  to  be  followed  by  a  relapse  or  by  the  development  of  a 
chronic  condition  of  a  most  intractable  description.  The  sooner  the 
patient's  stomach  can  be  got  to  digest  and  absorb  beefsteak  and  iron, 
the  more  speedy  will  be  her  recovery. 

In  pelvic  exudations  the  hot  vaginal  douche,  warm  baths,  and  the 
application  of  flannels  wrung  out  in  water  to  the  abdomen  aid  in  di- 

*  PitZe  Price,  Early  Operation  in  Purulent  Peritonitis,  Med.  News.  Aug.,  1890,  p. 
143  :  Discussion  on  Dr.  Geo.  Shoemaker's  paper  on  Puerperal  Septic;pmia  before  the 
Obst.  Soc.  of  Philadelphia,  the  Am.  Jour.  Obst.,  Nov.,  1889.  p.  1194;  Maury,  The 
Indications  for  Laparotomy  in  the  Treatment  of  Puerperal  Fevers,  Trans,  of  the 
Am.  Gryn.  Soc,  1891,  p.  248 ;  Hirst,  The  Position  of  Abdominal  Section  in  the 
Treatment  of  Septic  Peritonitis  after  Childbirth,  idem,  p.  461. 


tjQQ  DISEASES  OP  CHILDBED. 

minishing  the  local  pain,  and,  perhaps,  in  catising  a  disappearance  of 
the  tumor.  The  action  of  mercurials  or  of  iodide  of  potassium  in 
melting  away  plastic  inflammatory  materials  is  sometimes  very  strik- 
ing, but  more  frequently  they  either  do  no  good  or  else  do  harm  by 
disturbing  the  digestion. 

If  fever,  chills,  and  sweating  announce  the  presence  of  pus,  the 
most  careful  exploration  should  be  made  to  determine,  if  possible,  the 
seat  of  suppuration.  It  is  of  great  advantage  to  treat  pelvic  abscesses 
as  abscesses  are  treated  elsewhere  in  the  body.  If  the  redness  of  the 
skin  above  Poupart's  ligament  indicates  a  tendency  to  point  in  that 
direction,  an  aspirator-needle  should  be  introduced  to  make  sure  of 
the  diagnosis.  If  the  sac  is  near  the  surface,  a  free  incision  should 
be  made  and  the  pus  should  be  allowed  to  escape.  In  many  cases,  I 
make  these  incisions  three  to  four  inches  in  length.  The  redness  of 
the  external  skin  makes  it  certain  that  the  abscess  has  become  adherent 
to  the  abdominal  wall,  and  that  the  incision  consequently  will  not 
communicate  with  the  peritonaium.  After  the  abscess  has  been  opened 
it  should  be  cleansed,  and  the  cavity  should  be  filled  with  iodoform 
gauze.  I  can  recommend  this  plan  as  essentially  a  mild  procedure. 
With  a  large  opening  for  the  discliarge  of  pus,  the  fever  and  sweating 
disappear,  the  appetite  returns,  and  the  abscess  fills  rapidly  by  granu- 
lation. With  a  small  incision,  hectic  is  apt  to  pensist,  and  the  abscess 
to  end  in  the  formation  of  interminable  fistula?. 

If  softening  and  bagginess  or  distinct  fluctuation  indicate  that  the 
pus  can  be  reached  through  the  vaginal  cul-de-sac,  the  aspirator- 
needle  should  be  inserted-  deeply  at  the  suspected  point,  and,  if  a  large 
amount  of  pus  is  detected,  an  incision  should  be  made  with  a  long- 
handled  bistoury,  using  the  needle  as  a  director,  and  nuiking  the 
opening  large  enough  to  permit  thorough  irrigation  with  a  disinfect- 
ant douche,  and  packing  of  tiie  cavity  with  iodoform  gauze.  With 
drainage  and  cleanliness,  cases  of  the  longest  standing  may  be  expected 
to  recover. 

P.  F.  Mund6  *  has  reported  a  number  of  cases  of  chronic  character 
where  the  aspiration  of  pus  has  been  followed  by  rapid  absorption  of 
the  intrapelvic  exudation.  The  presence  of  pus  was  suspected  be- 
cause of  a  boggy,  doughy  feeling  in  the  exudation  tumor.  In  a  certain 
number  of  cases,  however,  the  patient  is  saved  from  chronic  invalidism 
only  by  abdominal  section  and  the  removal  of  pus-containing  tubes  or 
ovaries. 

*  Diagnosis  and  Treatment  of  Obscure  Pelvic  Abscess,  etc.,  Arch,  of  Med.,  De- 
cember, 1880. 


PUERPERAL  INSANITY.  YOl 

CHAPTER  XXXVII. 

PUERPERAL  INSANITY.  —  PHLEGMASIA    ALBA    DOLENS.  — DIS- 
EASES OF   THE  BREASTS. 

The  insanity  of  pregnancy,  of  childbed,  of  lactation.— Phlegmasia  alba  dolens.— 
Defective  milk  secretion. — Galactorrhoea. — Sore  nipples. — Subcutaneous  inflam- 
mation of  the  breast. — Submammary  abscess. — Parenchymatous  mastitis. — 
Galactocele. — Prophylaxis  of  ophthalmia  neonatorum. 

The  Ixsaxity  of  Pkegnancy,  Childbed,  and  Lactation. 

When  we  remember  the  marked  perturbation  of  the  nervous  sys- 
tem, in  even  normal  pregnancy,  from  reflex  causes,  from  disorders  of 
the  digestion,  and  from  depravation  of  the  blood,  it  is  not  strange 
that  the  same  conditions  which  give  rise  to  moral  perverseness,  to 
the  loss  of  memory,  to  hysteria,  or  to  hypochondria,  should  likewise 
prepare  the  way  for  the  outbreak  of  the  more  pronounced  forms  of 
mental  derangement.  In  character,  the  psychical  disturbances  of  child- 
bearing  women  do  not  differ  from  those  which  develop  under  ordinary 
circumstances ;  but  so  active  are  the  causes  during  the  period  in  ques- 
tion that  of  the  insane  who  crowd  the  public  asylums,  in  one  eighth, 
according  to  Tuke,  the  malady  is  of  puerperal  origin.  In  many 
women  there  exists  in  advance  an  hereditary  disposition  to  insanity, 
the  events  of  pregnancy  and  childbed,  which  are  commonly  associated 
with  the  ultimate  attack,  acting  simply  as  the  sparks  which  fire  the 
mine. 

During  pregnancy  the  prevailing  form  of  mental  disturbance  is 
melancholia,  Avith  sometimes  a  tendency  to  suicide.  The  prognosis  is 
favorable  when  the  disease  develops  in  the  early  months  and  follows 
physiological  depression  and  hypochondria  ;  unfavorable  in  severe  at- 
tacks occurring  first  in  the  latter  half  of  pregnancy,  or  where  preg- 
nancy intervenes  in  the  case  of  insanity  previously  existing.  As  a  rule, 
these  patients  can  be  best  cared  for  in  Avell-regulated  private  institu- 
tions, where  they  are  not  subjected  to  the  good-intentioned  expostula- 
tions of  intimate  friends. 

The  pains  of  labor  in  excitable  persons  are  said  to  give  rise  at  times 
to  a  transitory  delirium ;  but  this  certainly  is  of  very  rare  occurrence 
in  these  days  of  anesthetics.  The  indications  for  treatment  are,  of 
course,  to  relieve  the  pain  and  to  hasten  the  birth  of  the  child. 

Mania  may  occur  in  any  severe  puerperal  affection.  It  has  been 
observed  not  only  in  the  various  forms  of  metritis,  but  even,  accord- 
ing to  Winckel,  as  a  result  of  sore  nipples  and  very  painful  inflam- 
mations of  the  breasts.  The  delirium  in  these  cases  rises  and  falls 
with  the  fluctuations  in  the  underlying  malady,  and  is  thought  to  be 
dependent  upon  associated  cerebral  hyperaemia.  The  maniacal  mani- 
festations may  consist,  when  there  is  freedom  from  suffering,  of  agree- 


Y02  DISEASES  OP  CHILDBED. 

able  hallucinations— the  patient  often  singing  or  wearing  on  her  face 
a  rapt  expression ;  or,  if  the  pain  is  great,  she  may,  on  the  other  hand, 
see  forms  Avhich  threaten  her,  so  that  in  terror  she  cries  for  help, 
springs  from  bed,  and  strips  off  her  clothes  in  the  effort  to  escape  the 
source  of  danger.  The  prognosis  depends,  of  course,  upon  the  gravity 
of  the  morbid  condition,  of  which  the  mania  is  only  a  symptom.  The 
treatment,  with  the  exception  of  dry  cold  to  the  head,  is  that  of  the 
main  affection. 

Again,  puerperal  mania  may  proceed  from  an  hereditary  predispo- 
sition or  from  diseases  antedating  pregnancy,  in  either  case  the  puer- 
peral state  acting  as  the  proximate  but  not  as  the  fundamental  cause 
of  the  outbreak.  The  attacks  may  be  accompanied  by  erotomania, 
by  nymphomania,  by  religious  anxiety,  or  by  the  cUlire  de  persecution. 
It  may  be  evoked  by  psychical  impressions.  It  occurs  at  an  early 
period  of  childbed,  when  the  strength  is  wasted  by  j)ain,  excitement, 
or  fever. 

Finally,  puerperal  mania  may  be  caused  by  exhausting  losses  of 
blood,  by  intense  pain,  by  eclampsia,  or  by  anything  which  occasions 
cerebral  congestion.  In  this,  the  so-called  idiopathic  form  of  puer})eral 
mania,  the  attack  is  generally  preceded  by  sleeplessness,  indistinctness 
of  speecli,  by  restless  movements,  and  the  refusal  to  take  food.  At 
the  beginning  of  the  attack  the  delirium  is  usually  of  a  noisy  charac- 
ter, the  patients  screaming,  praying,  or  preaching  in  a  declamatory 
fashion ;  or  they  try  to  get  out  of  bed  and  to  escape  from  the  room  by 
the  doors  or  windows.  Sexual  excitement  is  rare,  the  disposition  to 
strip  off  the  night-dress  and  ex})ose  tlie  jjcrson  proceeding  not  from  an 
erotic  impulse,  but  from  a  desire  to  escape  from  some  fancied  restraint. 
Attempts  to  control  these  patients  by  force  are  apt  to  excite  them  to 
renewed  violence.  This  acute  stage  is  followed  by  melancholia,  charac- 
terized by  weeping,  praying,  and  fears  concerning  tlie  commission  of 
the  unpardonable  sin.  As  a  result  of  the  mental  depression,  suicidal 
tendencies  develop  in  a  considerable  proportion  of  the  cases.  The 
period  at  which  the  outbreak  first  attracts  notice  occurs  most  fre- 
quently within  the  first  two  weeks. 

The  indications  for  treatment  are  to  check  profuse,  exhausting  dis- 
charges, to  support  the  patient's  strength,  and  to  insure  perfect  quiet. 
AVith  the  first  sign  of  trouble,  the  child  should  be  taken  from  the  breast, 
liquid  food  should  be  given  at  frequent  intervals,  care  should  be  taken 
to  keep  the  bladder  and  the  rectum  empty,  the  room  should  be  dark- 
ened, and  its  temperature  should  be  regulated.  The  activity  of  the 
skin  should  be  promoted  by  means  of  the  sponge-bath.  The  sacrum 
should  be  watched  and  strapped  with  adhesive  plaster  if  bed-sores 
threaten.  Furniture,  pictures,  or  any  articles  which  disturb  the  patient 
should  be  removed  from  her  sight.  There  is  no  condition  in  which 
trained   nursing   can   do  so   much   toward   effecting   recovery.      The 


PUERPERAL  INSANITY.  Y03 

nurse's  duties  are  to  administer  food,  to  see  that  urination  is  regularly 
performed,  to  keep  the  patient  covered,  and  to  prevent  her  from  doing 
harm  to  herself  or  others.  Members  of  the  household  who  can  not 
resist  the  impulse  to  show  the  insane  woman  the  folly  of  her  delusions 
should  be  regarded  as  disqualified  from  entering  the  sick-room.  Pas- 
toral visits  are  rarely  beneficial.  If  the  patient  becomes  violent,  it  is 
usually  possible  for  the  family  physician  to  obtain  obedience  without 
the  exercise  of  restraint  or  force.  So  important  is  the  question  of 
personal  influence  in  the  management  of  puerjaeral  insanity  that  the 
success  of  home  treatment  is  almost  wholly  dependent  upon  the  con- 
trol which  the  physician  has  acquired  over  the  morale  of  his  patient 
previous  to  the  occurrence  of  her  malady.  Narcotics  do  not  cure,  but 
when  they  produce  a  few  hours'  sleep  they  certainly  promote  recovery. 
There  is  hardly  one  in  the  entire  list  which  has  not,  at  some  time,  done 
me  good  service.  My  preference  is  for  chloral  and  the  bromide  of  po- 
tassium (aa  gr.  xxx)  in  solution,  and  administered  by  the  rectum.  To 
procure  an  effect  from  moderate  doses,  it  is,  however,  necessary  that 
the  narcotic  be  given,  not  during  the  period  when  the  patient  is  most 
voluble  and  restless,  but  either  after  she  has  become  quieted  by  judi- 
cious management  or  during  a  natural  interval  of  calm.  Cold  to  the 
head  is  often  very  effective  in  relieving  headache  and  cerebral  conges- 
tion. If  the  stage  of  exaltation  passes  into  that  of  melancholia,  the 
question  of  continued  home-treatment  becomes  a  serious  one.  The 
mother  sometimes  exhibits  not  only  indifference,  but  even  a  positive 
dislike,  to  her  child,  which  makes  it  a  risky  thing  to  leave  them  alone 
together.  Again,  owing  to  the  suicidal  tendencies  which  often  go  with 
melancholia,  it  never  is  safe  to  allow  the  patient  to  pass  out  of  observa- 
tion, as  is  shown  by  the  following  case :  A  young  woman,  after  her  first 
confinement,  had  an  attack  of  mania,  for  which  she  was  sent  to  a  pri- 
vate asylum.  Shortly  after,  she  was  removed  by  her  friends  to  her  own 
home.  There  her  sweetness  and  passive  resignation  disarmed  sus- 
picion. One  day,  however,  she  dropped  her  sewing,  put  on  her  hat, 
and,  bidding  her  mother  a  pleasant  good-by,  walked  quietly  down  to 
the  river— a  half-mile  away— and  composedly  lay  down  in  the  shallow 
stream,  near  the  bank,  so  that  the  water  covered  her  face.  From  this 
position  she  was  rescued  by  some  men  who  were  mowing  in  a  field  near 
by,  and  by  them  was  carried  insensible  to  her  home.  The  next  day  she 
was  returned  to  the  asylum,  where  she  soon  made  a  good  recovery. 

The  insanity  of  lactation  is  either  the  result  of  cerebral  anaemia  or 
a  relapse  from  a  previous  attack.  It  begins,  as  a  rule,  six  to  ten  weeks 
after  confinement.  In  most  cases  it  assumes  the  form  of  melancholia. 
The  prognosis  is  good  if  the  disease  is  treated  in  season,  by  stopping 
lactation  and  by  removing  the  debility  upon  which  it  depends. 

In  general,  the  prognosis  of  puerperal  mania  is  favorable,  more  than 
sixty  per  cent,  of  the  cases  ending  in  recovery.     In  private  practice  the 


704 


DISEASES  OF  CHILDBED. 


number  is  probably  much  larger.  During  convalescence  care  should 
be  taken  to  secure  to  the  patient  rest,  sleep,  nutritious  food,  and  a  daily 
evacuation  of  the  bowels,  and  little  by  little  she  should  be  brought  back, 
once  more,  to  old  habits  and  the  responsibilities  of  existence. 

Phlegmasia  Alba  Dolens. 

Phlegmasia  alba  (Mens  is  the  term  applied  to  a  swelling  of  one  or 
both  lower  extremities,  occurring  usually  between  the  tenth  and  twen- 
tieth day  after  confinement,  and  characterized  by  pain,  tension  of  the 
skin,  and  a  milk-like  whiteness  of  the  surface.  Owing  to  its  color 
and  its  supposed  origin,  it  has  received  the  popular  name  of  milk-leg. 
Phlegmasia  is  an  affection  of  the  connective  tissue,  and  is  associated  in 
most,  but  not  in  all,  cases  with  thrombosis  of  the  veins. 

The  origin  of  the  swelling  is  somewhat  obscure.  In  a  certain  pro- 
portion of  cases  phlegmasia  is  obviously  the  extension  of  an  inflamma- 
tory process  from  the  genital  organs  to  the  perinaeum,  the  nates,  and 
the  upper  portion  of  the  thig^h.  If  confined  to  the  subcutaneous  and 
intermuscular  cellular  tissue,  the  vessels  may  not  become  affected. 
When,  however,  the  morbid  changes  follow  the  sheaths  of  the  vessels, 
the  walls  of  both  veins  and  lymphatics  tliicken,  and  in  most  cases  sec- 
ondary thrombus  formation  results. 

In  other  instances,  the  thrombus  formation  is  apparently  the  pri- 
mary lesion.  It  may  occur  spontaneously  from  slowing  of  the  blood- 
current.  A  predisposition  to  thrombosis  is  created  by  varicose  veins. 
The  vessels  usually  involved  are  the  crural  and  its  branches,  the  tibial 
and  peroneal  veins.  Again,  the  intravenous  coagula  may  start  from 
the  placental  site,  and,  extending  along  the  pampiniform  plexus  to  the 
hypogastric  vein,  may  thence  occlude  the  crural  to  Poui)art's  ligament, 
or,  passing  upward  by  the  spermatic  veins,  they  may  obstruct  the  vena 
cava.  Sometimes  the  occlusion  of  one  crural  vein  is  succeeded  by  that 
of  the  other,  phlegmasia  in  that  case  developing  in  both  extremities. 

Thrombus  formation  may  begin  during  pregnancy,  and  is  then 
usually  attended  with  pain  at  the  seat  of  trouble,  and  with  stiffness  in 
the  toes  or  the  dorsum  of  the  foot.  As  a  rule,  however,  the  disease  is 
rare  before  the  second  week  following  labor.  Often  it  is  preceded  by 
gastric  disturbances,  as  lack  of  appetite,  a  furred  tongue,  and  consti- 
pation, by  chilly  sensations,  and  by  a  heavy  feeling  in  the  affected  limb. 
A  careful  examination  sometimes  reveals  the  existence  of  inflamed  or 
thrombosed  veins  in  the  leg,  in  the  popliteal  space,  or  upon  the  inner 
surface  of  the  upper  portion  of  the  thigh.  If  the  affected  veins  are 
superficial,  the  redness  and  swelling  may  be  obvious  to  the  eye. 

The  first  characteristic  symptom  is  the  development  in  the  limb  of 
a  dull,  dragging  pain,  which  is  increased  by  motion.  Tenderness  to 
pressure  is  only  experienced  along  the  course  of  inflamed  vessels. 

In  primary  thrombosis,  the  swelling  usually  begins  at  the  ankls; 


PHLEGMASIA  ALBA    DOLENS.  7O5 

and  spreads  rapidly  to  the  knee  and  upward  to  tlie  inguinal  region ; 
in  secondary  thrombosis,  extending  from  the  uterine  sinuses,  and  in 
the  superficial  form  of  phlegmasia,  the  swelling,  on  the  contrary,  trav- 
els commonly  in  the  reverse  direction,  viz.,  from  the  inguinal  fold  to 
the  ankle. 

The  onset  may  or  may  not  be  announced  by  a  chill.  Fever  often 
precedes  and  accompanies  the  attack.  It  is,  however,  in  uncompli- 
cated cases,  of  a  mild  type,  and  sinks  to  the  normal  point  long  before 
the  swelling  of  the  limb  subsides.  Severe  chills  and  intense  fever, 
with  marked  remissions,  are  symptomatic  of  metastatic  pyaemia.  Other 
complications  may  essentially  modify  the  course  of  the  disease.  The 
pain,  the  tenderness,  and  the  febrile  disturbance  are  usually  greatest 
in  the  phlegmonous  form  of  swelling,  which  starts  from  the  genital 
organs. 

The  ordinary  termination  of  phlegmasia  is  by  absorption  of  the 
thrombus,  with  restoration  of  the  circulation.  As  this  takes  place, 
the  tension  of  the  skin  subsides  and  the  parts  pit  upon  pressure,  as 
in  ordinary  oedema.  As  the  swelling  and  pain  subside,  the  mobility 
of  the  limb  becomes  restored.  The  period  of  extreme  tension  lasts,  as 
a  rule,  for  from  five  to  eight  days.  Recovery  takes  place  slowly,  the 
dispersion  of  the  tumor  requiring  from  three  to  six  weeks. 

A  less  common  result  consists  in  the  permanent  obliteration  of  the 
vessel  by  the  conversion  of  the  thrombus  into  a  solid  connective-tissue 
cord,  in  which  case  the  extremity  may  long  continue  heavy,  and  loco- 
motion be  attended  with  difficulty. 

In  rare  instances  the  process  may  terminate  in  suppuration  and 
abscess  formation.  The  prognosis  of  a  pus  collection  in  the  vicinity 
of  a  vessel,  resulting  from  periphlebitis,  is  usually  favorable,  the  symp- 
toms that  it  occasions  disappearing  when  the  abscess  is  opened  and 
the  pus  is  allowed  to  escape.  When  the  suppurative  process  is  of  a 
spreading  character,  undermining  the  skin  and  attacking  the  inter- 
muscular cellular  tissue,  the  destructive  changes  may  assume  frightful 
proportions.  Thus,  in  hospital  practice,  we  sometimes  witness  cases 
where  the  muscles  are  dissected  from  one  another,  and  are  bathed 
in  an  ichorous  fl^iid,  with  greenish  particles  of  necrosed  tissue  adher- 
ing to  them,  death  ensuing  from  intense  septicaemia. 

Sometimes  a  thrombus  becomes  infected  and  undergoes  puriform 
softening,  with  detachment  of  small  particles,  which,  entering  the  cir- 
culation, give  rise  to  infarctions  and  metastatic  abscesses ;  or  a  large 
fragment  may  be  separated  accidentally  from  a  normal  clot,  and,  pass- 
ing by  the  vena  cava  and  the  right  side  of  the  heart,  may  cause  sudden 
death  by  plugging  the  pulmonary  artery. 

The  prognosis,  from  what  has  been  said,  is  evidently   dependent 
upon  the  origin  of  the  phlegmasia  and  upon  the  nature  of  the  com- 
plications.     The  principal  indications  for  treatment  are,  opium  to  al- 
45 


YQg  DISEASES  OF  CHILDBED. 

leviate  pain,  cathartics,  if  needed,  to  unload  the  bowels,  quinine,  iron, 
and  good  food  to  sustain  the  strength,  and  rest  for  the  swollen  ex- 
tremity. The  latter  should  be  raised  somewhat  higher  than  the  body, 
and  during  the  early  stages  of  the  swelling  should  be  wrapped,  as  rec- 
ommended by  Dr.  Fordyce  Barker,  in  cotton-batting  and  oil-silk.  The 
tenderness  should  be  mitigated  by  the  application  of  soothing  liniments. 
If  vesicles  form  upon  the  surface,  they  should  be  punctured  and  the 
fluid  be  allowed  to  escape.  When  the  extremity  begins  to  pit  on  press- 
ure and  the  tenderness  to  subside,  absorption  should  be  promoted  by 
gentle  frictions  with  alcoholic  lotions  and  by  bandaging  the  entire 
limb  evenly  with  a  flannel  roller.  Until  every  trace  of  tenderness  and 
thickening  has  disappeared  from  the  veins  the  patient  should  under 
no  circumstances  be  allowed  to  leave  her  bed.  The  danger  of  death 
from  sudden  obstruction  of  tlie  pulmonary  artery  is  always  present 
until  the  thrombus  has  disappeared  or  become  firmly  organized. 

For  some  time  after  recovery  has  taken  place  the  limb  will  swell,  as 
the  result  of  standing  or  of  protracted  exercise,  a  condition  which,  as  a 
rule,  is  greatly  benefited  by  the  patient  wearing  a  long  elastic  stocking. 

Diseases  of  the  Breast. 

Defective  Milk-secretion. — A  scanty  milk-secretion,  due  to  lack  of 
mammary  development,  to  extreme  youth,  to  polysarcia,  or  to  the 
mature  age  of  the  mother,  is  not  amenable  to  treatment.  Temporary 
insufficiency,  resulting  from  defective  nutrition,  may  sometimes  be 
remedied  by  a  regulated  nitrogenized  diet,  by  the  tincture  of  iron,  an 
outdoor  life,  and  by  the  consumption  of  large  quantities  of  fluid.  A 
diet  composed  for  the  most  part  of  milk  is  strongly  to  be  recom- 
mended. If  the  baby  is  feeble,  and  sleeps  or  cries  when  put  to  the 
breast,  it  is  a  good  plan  for  the  mother  to  borrow,  for  a  time,  a  healthy 
infant  with  strong  suction  powers  to  stimulate  the  glands  to  perform 
their  functions.  Cataplasms  of  castor-oil  leaves  or  fennel-teas  possess 
no  claims  to  confidence. 

Galactorrhoea. — An  abundance  of  milk  is  not  pathological,  the 
quantity  quickly  accommodating  itself  to  the  wants  of  the  child.  A 
constant  dribbling  of  milk  from  the  nipple,  or  (jalactorrlicea^  an  affec- 
tion which  may  continue  long  after  lactation  has  been  suspended,  acts, 
like  any  other  profuse  discharge,  in  exhausting  the  strength  and  in 
producing  a  wasting  of  the  tissues.  The  treatment  consists  in  inter- 
rupting lactation,  in  compression  of  the  breasts,  and  in  the  employ- 
ment of  such  dietetic  measures  as  are  best  calculated  to  repair  the 
general  health ;  of  special  measures,  saline  laxatives  and  the  internal 
administration  of  iodide  of  potassium  are  of  most  repute. 

Sore  Nipples. — Under  the  term  sore  nipples  are  included  a  number 
of  lesions  which,  in  spite  of  their  seeming  triviality,  possess  consider- 
able importance,  not  only  on  account  of  the  suffering  they  occasion, 


DISEASES  OP  THE  BREAST.  ^qY 

but  because  thoy  furnish  tlie  starting-iioint  of  most  cases  of  mammary 
abscess. 

A  simple  erytliema,  associated  with  great  tenderness,  is  a  common 
trouble  at  the  beginning  of  lactation,  to  which,  however,  jn-imiparai 
are  more  subject  than  multiparc^.  It  is  a  good  plan  to  anticipate  this 
difficulty  by  instructing  the  patient  to  wash  the  nipples  daily,  during 
the  last  weeks  of  pregnancy,  with  some  astringent  or  alcoholic  solu- 
tion. In  childbed,  in  addition  to  strict  cleanliness,  great  benefit  is 
derived  from  folding  a  linen  rag  around  tbe  nipple  and  keeping  it  con- 
stantly wetted  with  Goulard's  extract,  a  teaspoonful  to  a  tumbler  of 
water,  until  the  sensitiveness  and  redness  have  disappeared.  Before 
applying  the  child  to  the  breast,  care  should  be  taken  to  wash  away 
the  deposited  carbonate  of  lead. 

In  many  women,  owing  to  the  maceration  and  loosening  of  the 
epithelium  from  the  oozing  of  the  colostrum,  suckling  of  the  child  is 
followed  by  the  formation  of  small  vesicles,  which  eventually  rupture 
and  produce  isolated  erosions.  Under  favorable  conditions,  these  ero- 
sions become  covered  with  crusts  beneath  which  the  healing  process 
takes  place.  If,  however,  the  crusts  are  removed  by  suckling  before  a 
new  layer  of  epithelium  has  had  time  to  form,  the  simple  excoriation 
may  be  converted  into  an  ulceration  with  deep  destruction  of  tissue. 
If  the  child  be  suffering  from  sprue,  the  transfer  of  the  oi'dium  albicans 
may  impart  to  the  wounds  of  the  nipple  an  aphthous  character.  If  the 
primary  vesicles,  in  place  of  remaining  isolated,  coalesce,  the  nipple 
may  become  bared  of  its  epithelium,  over  a  considerable  extent  of  its 
surface.  The  papillae  then  enlarge  and  give  a  raspberry-like  appear- 
ance to  the  exposed  structure. 

Fissures  of  the  nipples  are  excruciatingly  painful,  and  are  capable 
of  exciting  even  a  high  degree  of  fever.  They  occur  with  greatest  fre- 
quency in  nipjiles  which  have  been  flattened  by  the  pressure  of  corsets, 
or  in  Avhich  the  natural  fissures  between  the  papillae  are  of  unusual 
depth.  Most  commonly  they  are  seated  at  the  base  of  the  organ. 
Either  they  may  develop  from  the  erosions  just  described,  or  the  clefts 
upon  the  surface  may  become  covered  by  crusts  composed  of  dirt  and 
colostrum,  which,  when  torn  away  by  the  nursing  child,  detach  the 
delicate  underlying  epithelium. 

As  regards  the  treatment,  it  is  well  to  bear  in  mind  that,  with 
cleanliness  and  the  removal  of  irritating  matters  from  the  wounded 
surface,  the  worst  cases  of  sore  nij^ples  will  get  well  in  from  twenty- 
four  to  forty-eight  hours,  provided  lactation  is  suspended.  The  object 
of  treatment,  therefore,  is  to  cure  the  lesion  without  interfering  with 
the  nursing  of  the  child.  This  is  comparatively  easy  when  but  one 
nipple  is  affected,  as  the  child  need  only  be  applied  to  tlie  sound  side. 
In  that  case,  however,  the  excessive  tension  which  results  from  the 
suspension  of  lactation  should  be  relieved  by  stroking  the  breast  from 


Yog  DISEASES  OF  CHILDBED. 

the  base  toward  the  apex  with  the  hands,  or  by  getting  the  nurse  to 
draw  the  milk  with  her  mouth,  or  by  means  of  a  breast-pump  with  a 
wide,  trumpet-shaped  extremity.  The  healing  process  can  at  the  same 
time  be  promoted  by  lead-loLions,  by  a  solution  of  tannin,  or  by  some 
astringent  ointment.  My  rule  is  to  keep  upon  the  nipple  a  rag  wet- 
ted with  the  Goulard's  extract,  as  described  for  erythema,  during  the 
patient's  waking  hours,  substituting  therefor  a  carbolized  ointment 
during  the  hours  of  sleep,  when  the  drying  of  a  lotion  would  cause  the 
rag  to  adhere  to  the  raw  surface.  If  the  child  be  troubled  with  sprue, 
special  attention  must  be  taken  to  cure  its  mouth,  and  the  develop- 
ment of  the  oidium  albicans  upon  the  nipple  should  be  prevented 
by  frequent  washings  with  solutions  of  boracic  acid  or  of  the  sulphite 
of  sodium. 

Cracks  are  much  more  rebellious  to  treatment  than  simple  erosions. 
If  of  any  extent,  the  nipple  should  be  drawn  to  one  side,  so  as  to 
expose  the  fissure,  which  should  be  touched  with  the  point  of  the 
mitigated  stick  of  nitrate  of  silver.  As  the  effect  of  the  latter  is 
intended  to  be  local,  it  should  be  applied  dry,  the  lymph  furnished 
by  the  denuded  surface  affording  the  requisite  moisture.  I  mention 
this  trivial  detail,  as,  in  hospital  practice,  I  have  sometimes  seen  the 
entire  nipple  robbed  of  its  epithelium,  owing  to  the  mistake  made 
by  the  house-physician  of  first  dipping  the  pencil  in  water,  and  then 
allowing  the  strong  solution  to  diffuse  itself  over  the  sensitive  sur- 
face. The  compound  tiiu-ture  of  benzoin,  strongly  recommended  by 
Professor  Fordyce  liarker,  makes  a  good  stimulating  application  to 
cracks  of  the  nipple.  Though  somewhat  painful,  when  used  for  the 
first  time,  it  is  afterward  easily  tolerated. 

If  both  nipples  are  simultaneously  affected,  lactation  can  not  of 
course  be  entirely  interrupted  without  drying  up  the  milk,  but  the 
intervals  between  the  acts  of  nursing  should  be  lengthened  as  much  as 
the  comfort  of  the  mother  will  permit.  If  the  milk  will  not  come 
without  tugging,  the  flow  should  be  furthered,  before  ap]ilying  the 
child,  by  stroking  the  breasts.  Of  nipple  shields  I  am  not  able  to 
speak  with  much  enthusiasm.  Many,  if  not  most,  infants  resent  the 
ordinary  rubber  ones,  and  refuse  to  suck  through  them.  A  more 
acceptable  form  is  one  provided  with  a  rubl^er  tu1)e  ami  mouth-piece 
such  as  commonly  goes  with  nursing-bottles,  but  it  is  apt  to  drive 
away  the  milk  if  its  use  is  long  persisted  in.  Legroux  recommends  a 
bit  of  gold-beater's  skin,  fastened  to  the  breast  by  means  of  collodion, 
and  perforated  with  a  needle  over  the  portion  which  covers  the  open- 
ings of  the  lactiferous  ducts.  But,  even  without  these  aids,  in  time  a 
cure  can  usually  be  effected  by  perseverance  in  the  use  of  the  remedies 
already  mentioned.  It  is  necessary  to  stop  nursing  altogether  only 
when  the  nipples  are  hopelessly  flat  and  misshapen,  or  when  mastitis 
threatens. 


DISEASES  OF  THE  BREAST.  Y09 

For  eczema,  lead,  zinc,  or  white-precipitate  ointment  may  be  em- 
ployed. In  obstinate  cases,  a  solution  of  corrosive  sublimate  (gr.  v  ad 
3  J)  is  recommended  by  Hebra. 

Subcutaneous  Inflammation  of  the  Breasts.— The  subcutaneous  in- 
flammation may  be  confined  to  the  areola,  which  then  becomes  red, 
swollen,  and  excessively  sensitive.  This  form  generally  terminates  in 
suppuration,  and  may  form  fistulous  communications  with  the  lactif- 
erous ducts.  Sometimes  the  inflammation  begins  in  the  sebaceous 
follicles,  giving  rise  to  small  boils  around  the  nipple. 

In  other  cases  inflammation  may  extend  beyond  the  areola,  and 
either  give  rise  to  localized  abscesses,  or,  when  due  to  the  septic  infec- 
tion of  excoriated  nipples,  assume  an  erysipelatous  character. 

The  treatment  of  both  these  forms  consists  in  the  application  of 
warm  lead-lotions,  and  in  the  early  evacuation  of  the  pus.  To  avoid 
cutting  into  tlie  milk-ducts,  the  incision  should  radiate  from  the  nipple. 

Inflammation  of  the  Submammary  Connective  Tissue. — This  rare 
condition  owes  its  origin,  according  to  Billroth,  in  most,  if  not  in  all, 
cases  to  abscess  formation  in  the  deep-lying  glandular  structures,  the 
pus  perforating  the  fascia-like  connective  tissue  at  the  base  of  the  organ 
into  the  loose  connective  tissue  situated  between  the  gland  and  the 
pectoral  muscle.  The  breast  is  in  consequence  lifted  from  the  trunk, 
and  can  be  moved  to  and  fro,  as  though  it  rested  upon  a  water-bed. 
The  skin  is  not  reddened,  but  is  sometimes  markedly  cedematous. 
The  pain  is  deep-seated  and  dull ;  the  fever  is  high  and  continuous ; 
the  axillary  glands  swell,  and  movements  of  the  arm  are  hindered  by 
the  increase  of  the  i^ain  they  occasion.  Stoltz  is  said  to  have  removed 
from  such  a  sac  twenty  ounces  of  pus.  So  soon  as  the  pus  formation 
is  recognized,  and  the  fact  can  be  early  determined  by  means  of  an 
aspirator-needle,  a  free  incision  should  be  made  at  the  lower  portion 
of  the  gland,  and  the  wound  should  be  treated  with  the  antiseptic 
precautions  which  will  be  given  in  connection  with  parenchymatous 
mastitis. 

Parenchymatous  Mastitis. — Inflammation  of  the  glandular  struct- 
ures of  the  breast  develops  usually  in  the  first  four  weeks  after  confine- 
ment. It  is  characterized  by  pain,  high  fever,  and  nodular  enlarge- 
ment of  the  affected  lobules.  The  attack  usually  begins  Avith  a  sharp 
chill.  These  symptoms  are  sometimes  observed  three  to  four  days 
after  the  birth  of  the  child,  at  the  beginning  of  lactation,  but  then  are 
usually  temporary,  the  commencing  mastitis  terminating  in  sponta- 
neous resolution.  Mastitis  leading  to  abscess-formation  belongs,  for 
the  most  part,  to  a  later  period,  occurring  most  frequently  in  the 
third  or  fourth  week,  long  after  the  first  inflammatory  symptoms 
have  subsided. 

Puerperal  mastitis  is  quite  commonly  believed  to  be  due  to  emo- 
tional causes,  to  cold,  to  blows,  or  to  "  caking  "  from  milk  retention 


^^Q  DISEASES  OP  CHILDBED. 

—all  suppositions  of  extreme  convenience  as  relieving  the  physician 
from  responsibility  for  their  occurrence.  They  certainly,  however, 
play  a  subordinate  rule  in  tlie  etiology  of  the  affection,  the  lesions  of 
the  nipples  furnishing,  with  perhaps  rare  exceptions,  the  starting-point 
from  which  the  inflammation  travels  to  the  glands,  either  passing  to 
the  deep-seated  tissues  by  the  lymphatics,  or  following  the  track  of 
the  lactiferous  ducts  to  the  glandular  acini.*  The  exact  anatomical 
structure  of  the  resulting  nodular  masses  is,  for  the  most  part,  matter 
of  conjecture.  Only  this  much  is  known  certainly,  that  they  are 
composed  in  part  of  glandular  structures  and  in  part  of  the  swollen 
interstitial  tissue ;  tliat  the  lactiferous  ducts  are  either  constricted  or 
closed ;  that  suppuration  takes  place  both  in  the  connective  tissue  and 
in  the  acini ;  and  that  the  large  abscess-cavities  form  from  the  coales- 
cence of  small  pus-collections.  The  walls  of  the  abscess  are,  therefore, 
never  smooth,  but  are  uneven,  with  projecting  portions  of  glandular 
tissue  which  has,  as  yet,  not  undergone  disintegration.  The  milk- 
secretion  is  arrested  in  the  affected  lobules.  If,  as  sometimes  happens, 
a  large  duct  is  perforated,  pus  may  be  discharged  with  the  milk,  or,  in 
case  the  abscess  opens  externally,  a  milk-fistula  may  be  produced. 
When  several  foci  of  inflammation  exist,  they  may  suppurate  in  suc- 
cession, so  that  abscess  after  abscess  may  develop,  and  the  morbid 
condition  be  protracted  for  weeks,  and  even  months.  If  the  abscesses 
break  spontaneously,  at  a  point  unfavorable  for  the  discharge  of  pus, 
fistulous  passages  are  liable  to  be  produced.  In  hospitals,  as  the  result 
of  long-continued  suppuration  and  necrosis  of  tissue,  entire  lobes  may 
undergo  destruction,  with  subsequent  cicatricial  fonnation  and  ensu- 
ing deformity  of  the  breast ;  or,  with  the  access  of  unwholesome  air  to 
the  abscess-cavities,  the  sloughing  tissues  may  become  gangrenous  and 
death  may  follow  from  septicemia. 

The  first  important  point  as  regards  tlie  treatment  of  parenchyma- 
tous mastitis  is  to  take  the  child  from  the  breast.  If  this  is  done 
early,  in  a  very  large  number  of  cases  the  inflammation  will  disappear 
without  advancing  to  suppuration.  If  lactation  is  continued,  espe- 
cially when  sore  nipples  persist  as  a  complication,  tlie  chances  of 
avoiding  abscess-formation  are  extremely  small.  In  cases  of  pain  due 
to  excessive  fullness  of  the  milk-ducts,  partial  relief  should  be  given  by 
means  of  mammary  expression.  For  the  pain,  opium,  for  the  fever, 
a  full  dose  of  quinine,  should  be  administered.  A  saline  cathartic  acts 
as  a  derivative  and  diminishes  the  hyperaemia  of  the  breasts.     As  tlie 

*  Baum  (Zur  Aetiologie  der  puerperalen  Mastitis,  Arch.  f.  Gynaek.,  vol.  xxiv,  p. 
262)  discovered  diplococci  in  the  pus  obtained  from  a  mammary  abscess.  These 
diplococci  were  subjected  to  pure  culture,  and  in  the  fifth  generation  were  inoculated, 
by  means  of  a  hypodermic  syringe,  into  his  own  skin  and  into  that  of  two  other 
persons.  The  inoculations  were  followed  by  hardening,  fever,  suppuration,  and  the 
formation  of  sinuous  cavities. 


DISEASES   OF  THE   BREAST.  ^11 

pain  of  the  inflammation  is  augmented  by  the  weight  of  the  organ, 
the  breast  should  be  raised  and  supported  by  a  suitable  bandage.' 
Much  comfort  is  often  afforded  by  the  local  application  of  belladonna, 
in  the  form  either  of  an  ointment  or  of  the  liniment  diluted  with 
three  or  four  parts  of  opodeldoc.  Considerable  relief  is  likewise  ob- 
tained by  laying  a  flannel  wetted  with  a  lead-and-opium  wash  over 
the  breast,  and  placing  on  the  outside  some  water-proof  substance  to 
prevent  speedy  evaporation.  A  large  flaxseed-poultice  lessens  pain  by 
reason  of  its  heat,  but  should  not  be  employed,  at  least  so  long  as  the 
hope  of  absorption  has  not  been  abandoned.  Indeed,  previous  to 
suppuration,  dry  cold  (ice-bag),  which  is  both  sedative  and  antiphlo- 
gistic, deserves  the  preference.* 

So  soon  as  there  are  evidences  of  pus,  such  as  bogginess,  oedema, 
or  reddening  of  the  skin,  the  abscess  should  be  opened  with  antisep- 
tic precautions.  If  the  inflamed  acini  are  situated  near  the  surface, 
fluctuation  is  early  apparent.  In  deep-seated  abscesses,  the  precise 
situation  of  the  pus  collections  is  not  easy  to  determine.  If  the. 
matter  is  doubtful,  it  is  better  to  first  insert  an  aspirator-needle  into 
the  breast  rather  than  to  subject  the  woman  to  a  painful  operation, 
which,  if  misdirected,  may  require  to  be  repeated. 

In  Billroth's  clinic  f  the  following  plan  is  adopted  in  opening  ab- 
scesses of  the  breast :  The  surface  should  first  be  cleansed  with  soap 
and  drenched  with  a  solution  of  carbolic  acid  or  of  thymol.  The 
incision  should  be  a  half -inch  in  length,  and  should  radiate  from  the 
nipple.  A  drainage-tube  should  be  instantly  introduced,  and  the  pus 
should  be  gently  expressed,  after  which  the  breast  should  once  more  be 
bathed  with  a  disinfectant  fluid.  The  entire  breast  should  then  be 
enveloped  in  antiseptic  gauze  covered  with  water-proof  material. 
Finally,  after  packing  the  periphery  with  oakum,  especially  beneath 
the  breast  and  in  the  axilla,  the  dressing  should  be  fastened  with  a 
bandage  extending  over  the  thorax  from  the  neck  to  the  umbilicus. 
In  doing  this,  care  should  be  taken  to  pack  sufficient  cotton  beneath 
and  around  the  sound  breast  to  prevent  its  surface  being  pressed  into 
contact  with  that  of  the  thorax.  If  the  abscess  is  large  and  sinuous, 
the  dressing  should  be  changed  in  twenty-four  hours,'  and  then 
should  be  left  in  place  for  from  three  to  five  days.  By  these  means 
the  organ  is  equably  compressed,  the  pus  is  prevented  from .  decompos- 
ing, and  the  discharge  is  promoted,  all  conditions  which  tend  to  pro- 
duce a  painless  course  and  a  i-apid  recovery.  If,  while  the  bandage  is 
applied,  the  patient  once  more  suffers  from  pain  and  fever,  it  should 
be  removed,  and  any  new  abscess  in  the  process  of  formation  should 
be  opened  and  treated  in  the  same  manner. 

*  Vide  CoRSEN,  The  Treatment  of  Maiiiinary  Abscess,  Am.  Jour.  Obst.,  January, 
1881,  for  account  of  favorable  experiences. 

f  Billroth,  Handbuch  der  Frauenkrankheiten,  zehnter  Abschnitt,  p.  23. 


712 


DISEASES  OF  CHILDBED. 


By  the  practice  recommended,  even  in  bad  cases,  the  ugly  scars 
and  deformities  of  the  breast,  which  sometimes  follow  the  older  poul- 
tice treatment,  are  avoided. 

In  fresh  cases,  the  pus  is  never  decomposed,  and  irrigation  of  the 
wound  is  unnecessary.  In  old  cases,  on  the  contrary,  which  have 
been  treated  by  small  incisions  and  without  antiseptic  precautions,  the 
pus  is  often  acid,  and  possessed  of  irritating  properties.  For  these 
neglected  abscesses  I  can  enthusiastically  recommend  the  method  of 
Billroth,  which  consists  in  placing  the  patient  under  an  anaesthetic, 
enlarging  the  openings  so  as  to  permit  the  passage  of  the  finger,  and 
breaking  down  the  thin  partitions  between  the  abscesses,  so  as  to  con- 
vert them  as  far  as  possible  into  large  communicating  cavities  ;  while 
this  process  is  going  on,  the  tube  of  an  irrigator  should  be  passed  by 
the  side  of  the  finger,  and  tlie  cavity  should  be  waslied  with  a  3-per- 
cent solution  of  carbolic  acid  until,  at  last,  the  fluid  comes  away  clear 
and  unstained.  Drainage-tubes  should  then  be  introduced,  and  the 
breast  treated  in  tlie  antiseptic  manner  already  described.  By  this 
plan  I  have  succeede^l  in  closing  uj)  sinuses  of  long  standing  in  the 
course  of  two  to  three  weeks. 

It  is  hardly  necessary  to  add  that  the  recovery  of  the  patient  is 
always  aided  by  good  food  and  an  abundance  of  frcsli,  pure  air. 

Galactocele. — In  very  rare  cases,  owing  to  the  obliteration  or  stop- 
page of  one  of  the  milk-ducts,  the  sinus  may  become  distended  with 
milk,  and  form  a  cyst  termed  a  galactocele.  Usually  it  is  of  small 
size,  but  in  the  often-quoted  case  of  Scarpa  the  breast  attained  such 
dimensions  as  to  reach  to  the  thigh.  Upon  puncturing  the  tumor 
with  a  trocar,  ten  y)ounds  of  milk  were  removed,  which  in  all  respects 
resembled  human  milk  of  nornuil  quality. 

The  Prophylaxis  of  Ophthalmia  Neonatorum.— In  1881  Credo*  rec- 
ommended that,  in  lying-in  asylums,  as  a  ])reventive  measure,  the  eyes 
of  all  children  immediately  after  birth  should  be  washed  with  pure 
water,  and  that,  thereafter,  a  single  drop  of  a  2-per-cent  solution  of 
nitrate  of  silver  should  be  dropped  between  the  parted  lids  by  means 
of  a  glass  rod.  This  plan  has  since  been  tested  in  the  principal  ma- 
ternities of  Europe  with  the  most  satisfactory  results.  It  possesses  no 
apparent  drawbacks.  In  exceptional  instances,  swelling  of  the  lids, 
injection  of  the  conjunctiva,  and  a  hypersecretion  of  mucus  or  serum 
have  been  observed,  but  the  reaction  has  been  trivial,  and  has  disap- 
peared in  from  twenty-four  to  forty-eight  hours. 

*  Crede,  Die  Verhiitiing  der  Augen-Entzundung  der  Neugeborenen,  Arch.  f. 
Gynaek,  vol.  xvii,  p.  50,  and  vol.  xviii.  p.  367. 


APPENDIX. 


S  YMPH  YSIOTOMY.* 

The  doctrine  of  the  separation  of  the  pelvic  bones  due  to  soft- 
ening at  the  articulations  during  pregnancy,  and  especially  at  the  time 
of  labor,  was  taught  by  Hippocrates  and  Avicenna.f  Galen  maintained 
that  the  pelvic  symphyses  were  true  joints.  Vesalius,  on  the  other 
hand,  insisted  that  the  bones  of  the  pelvis  were  united  by  ordinary 
cartilage.  The  prestige  of  Vesalius  as  an  anatomist  exerted  a  great 
influence  upon  the  opinions  of  his  contemporaries.  When,  in  1519, 
Jacques  Amboise  invited  the  most  eminent  physicians  and  surgeons  of 
Paris  to  be  present  at  the  dissection  of  a  woman  executed  for  child 
murder  a  few  days  after  the  birth  of  the  child  had  taken  place,  few 
responded,  and  yet  on  this  occasion  he  demonstrated  that  a  separation 
of  the  pelvic  bones  existed,  and  that  it  was  not  a  pathological  condi- 
tion. Pinaeus,  who  was  present,  was  greatly  interested,  and  took  notes 
of  the  lecture,  the  leading  points  of  which  he  reproduced  in  a  brochure 
published  in  1575.  In  this  Pinaeus  stated  that  of  the  pelvic  Joints  the 
symphysis  was  most  affected.  The  synchondrosis,  he  said,  was  like  a 
sponge,  which  swelled  during  pregnancy,  and  became  dry  subsequently. 
The  resulting  softening  was  due  to  a  physiological  succulence  caused 
by  pregnancy.  He  recommended  the  employment  of  cataplasms,  of 
inunctions,  and  of  hip-baths  as  means  to  enhance  the  normal  process. 
To  aid  him  in  winning  converts  to  his  doctrine  he  associated  with  him 
the  eminent  physician  Riviere,  who  had  likewise  studied  the  physio- 
logical changes  at  the  Joints  due  to  pregnancy.  If,  said  Riviere,  one 
flexes  during  labor  both  thighs  upon  the  abdomen,  and  at  the  same 
time  everts  them,  the  foetus  descends  with  each  pain,  owing  to  the 
separation  at  the  symphysis.  Pinaeus  went  further,  and  said  one  might 
even  divide  the  symphysis  to  facilitate  difficult  labor,  and  quoted  Galen 
to  the  effect  that  the  contents  are  of  more  value  than  the  receptacle, 
and  that  one  ought  to  stretch  or  even  incise,  the  latter  in  the  interest 

*  From   Dennis'    System  of  Surgery,  vol.   iii,   by   permission  of   Messrs.  Lea 
Brothers  &  Co. 

f  For  these  historical  details  I  am  indebted  to  the  recent  work  of  Franz  Ludwig 
Neugebauer,  Ueber  die  Rehabilitation  der  Schamfugentrennung,  Leipsic,  1893. 

713 


714 


APPENDIX. 


of  the  former.  There  is  no  doubt,  says  Pinseus,  that  in  this  instance 
the  foetus  is  of  the  greater  importance. 

Among  the  eminent  authorities  whom  we  find  later  enlisted  on  the 
side  of  the  doctrine  that  the  pelvic  dimensions  are  increased  as  a  con- 
sequence of  pregnancy  and  labor  may  be  mentioned  Sylvius,  Fernel, 
Deleurye,  Riolauus,  and  Morgagni. 

As  a  fruit  of  these  studies  symphysiotomy  was  performed  as  a  sub- 
stitute for  the  Caesarean  section  with  the  view  of  saving  the  child  by 
Jean  Claude  de  la  Courvee  at  Warsaw  in  1585,  and  by  Plenck  in  Ger- 
many in  1766,  upon  women  who  had  died  during  labor. 

But  as  a  means  to  facilitate  labor  on  the  living  subject  in  cases  of 
contracted  pelvis  the  first  definite  proposition  came  from  Jean  Rene 
Sigault  in  1768,  while  he  was  a  student  of  medicine  in  Paris. 

The  first  actual  operation,  it  is  now  claimed,  was  performed  by 
Domenico  Ferrara  in  1774,  in  the  Hospital  for  Incurables  in  Naples. 
Ferrara  had  studied  in  Paris  and  had  heard  of  Sigault's  proposition  in 
1768.  The  case  ended  fatally,  but  it  possesses  a  special  interest  because 
it  was  in  the  same  hospital  that  a  century  later  Morisani  had  the  honor 
of  restoring  the  discredited  procedure  to  a  recognized  place  in  the 
practice  of  obstetrics. 

The  suggestion  to  employ  symphysiotomy  was  at  the  time  received 
by  the  Paris  Academy  of  Medicine  with  scant  favor,  but  in  1777  Sigault 
had  an  opportunity  to  subject  his  theoretical  views  to  a  practical  test. 
The  patient,  Mme.  Souchot,  the  wife  of  a  soldier,  was  three  feet  eight 
inches  high  and  thirty-nine  years  old.  The  pelvic  conjugate  was 
estimated  at  two  inches  and  a  half.  She  had  previously  been  confined 
four  times;  all  the  children  were  born  dead.  In  the  third  pregnancy 
labor  was  induced  at  the  eighth  month,  but  the  birth  was  very  difficult, 
and  was  followed  by  prolapse  of  the  vagina.  In  the  fourth  i)rcgnancy 
(1775)  Sigault,  despairing  of  obtaining  a  living  child,  wished  to  try 
symphysiotomy,  but  the  proposal  was  declined.  The  fifth  pregnancy 
occurred  in  1777.  Labor  began  on  the  30th  of  September.  The  head 
presented.  Meantime  the  patient  had  given  personal  thought  to  her 
case.  She  was  most  anxious  for  a  living  child.  She  had  heard  of  an 
operation  performed  experimentally,  with  a  favorable  result,  upon  a 
parturient  sow  by  Camper,  one  of  the  greatest  authorities  of  his  day. 
She  decided  therefore  to  submit  herself  to  the  novel  experiment.  She 
even  picked  the  necessary  lint,  and  cheered  her  despairing  husband 
with  the  hope  of  a  living  child. 

The  operation  was  performed  on  the  night  of  October  2d  by  the 
light  of  a  lamp  held  by  a  maid,  and  with  the  assistance  of  Alphonse 
Leroy,  the  future  historian  of  the  event.  Sigault  divided  the  symphy- 
sis with  an  ordinary  bistoury.  He  then  ruptured  the  membranes,  and, 
aided  by  Leroy,  extracted  a  living  child  by  the  feet.  The  separation  at 
the  symphysis  during  delivery  was  two  inches  and  a  half,  and  after  the 


SYMPHYSIOTOMY.  7I5 

birth  was  eight  lines.  The  hgemorrhage  was  trifling.  The  wound  was 
dressed  with  lint,  and  a  bandage  was  applied  to  the  pelvis.  The  pa- 
tient had  no  fever,  and  nursed  her  child.  On  the  fourth  day  the  band- 
age was  removed,  as  it  distressed  her ;  the  bowels  moved  on  the  sev- 
enth day;  there  was  at  first  incontinence  of  urine  from  injury  to  the 
urethra,  but  this  gradually  disappeared.  On  the  fourteenth  day 
Mme.  Souchot  moved  without  assistance  from  one  bed  to  another; 
on  the  twenty-fifth  day  she  sat  up  in  bed,  and  on  the  forty-sixth  day 
she  went,  unaided,  but  wearing  a  bandage,  down  four  flights  of  stairs 
to  the  street  and  to  church.  Afterward  she  walked,  resting  on  her 
husband's  arm,  up  the  steps  to  the  lecture-room  of  the  Faculty  of 
Medicine,  and  was  examined  by  a  number  of  the  professors. 

The  operation  naturally  caused  an  extraordinary  sensation.  The 
Faculty  of  Medicine  awarded  to  Sigault  a  silver  medal.*  Enthusiastic 
ovations  were  prepared  in  his  honor,  and  he  was  regarded  as  a  bene- 
factor of  the  human  race.  But  the  triumph  was  of  short  duration. 
The  French  Academy  of  Surgery  under  the  lead  of  Baudelocque  op- 
posed to  the  new  measure  a  most  determined  hostility.  The  ensuing 
cases  were  not  all  equally  successful.  It  is  not  now  easy  to  determine, 
amid  the  conflicting  statements  that  have  come  down  to  us,  the  exact 
truth  as  to  the  issue  of  those  early  operations. 

vSiebold  was  successful  in  saving  the  mother  in  1778.  Sigault  02:)cr- 
ated  six  times,  with  the  loss  of  one  mother  and  five  children.  Leroy  in 
four  operations  lost  one  mother  and  one  child.  De  Cambon  in  four 
cases  lost  one  mother  and  two  children.  It  musl  be  remembered  that 
at  the  time  mentioned  Caesarean  section,  the  rival  procedure,  was  in 
Paris  and  Vienna  nearly  uniformly  fatal. f  The  heavy  mortality 
among  the  children  was  probably  not  directly  connected  with  the  oper- 
ation, but  was  due  in  most  cases  to  the  conditions  which  furnished  the 
indications  for  the  operation  or  to  delays  in  its  performance. 

But  it  was  not  so  much  the  statistical  results  about  which  the  early 
combatants  were  concerned.  The  supporters  of  the  Cfesarean  section 
maintained  that  in  the  cases  is  which  symphysiotomy  was  advocated  as 
a  substitute  for  the  older  measure  the  increase  of  space  obtained  by 
division  of  the  symphysis  was  not  sufficient  to  permit  the  extraction  of 
the  living  child,  except  with  the  infliction  of  dangerous  injuries  to  the 
sacro-iliac  articulations.  In  proof  of  this  Baudelocque  demonstrated 
upon  the  cadaver  of  a  rhachitic  dwarf  that,  it  spite  of  symphysiotomy, 

*  "  Pour  recompenser  I'inventeur  d'une  decouverte  si  utile  a  i'humanite,  on  ferait 
graver  une  medaille  en  son  honneur  comine  temoignage  de  reconnaissance  et  d'ad- 
miration." 

f  Baudon  in  1873  wrote  that  there  had  not  been  a  successful  case  in  Paris  in 
eighty  years.  Spaeth,  before  the  appearance  of  Sanger's  well-known  work,  found, 
in  looking  over  the  records,  that  there  had  been  no  recovery  from  the  operation  in 
the  Vienna  lying-in  hospital  during  the  present  century. 


716 


APPENDIX. 


he  was  unable  to  procure  the  descent  of  the  head  into  the  pelvis,  even 
with  powerful  traction  by  the  forceps.  When,  finally,  he  succeeded  by 
the  employment  of  force  exerted  from  above,  combined  with  lateral 
pressure  applied  to  the  child's  head,  rupture  of  the  pelvic  joints  fol- 
lowed. In  the  fatal  cases  referred  to  which  occurred  in  the  practice  of 
Leroy,  of  Sigault,  and  of  Cambon  it  was  found  at  the  post-mortem 
examination  that  the  posterior  articulations  had  ruptured  and  were 
filled  with  pus.  However,  in  each  of  these  four  cases  the  conjugata 
vera  was  less  than  two  inches  and  a  half — a  degree  of  pelvic  contrac- 
tion which  recent  symphysiotomists  regard  as  contraindicating  the 
operation,  at  least  at  the  end  of  gestation. 

As  the  outcome  of  his  experiments  Baudelocque  concluded  that  sym- 
physiotomy was  admissible  only  in  cases  where  the  conjugata  vera  was 
not  less  than  two  inches  and  three  quarters,  and  that  the  divergence 
of  the  pubic  bone  should  not  be  allowed  to  exceed  one  inch.* 

In  the  cases  of  apparent  success  Baudelocque  alleged  that  the  oper- 
ation was  unnecessary,  and  that  Nature  or  the  forceps  would  alone  have 
sufficed  to  achieve  the  desired  result.  -It  was  of  course  natural  that  in 
those  tentative  days  the  after-effects  of  pubic  section  did  not  always 
correspond  to  the  expectations  of  its  advocates.  While  the  extent  of 
the  consecutive  injuries  was  doubtless  exaggerated  for  ])artisan  pur- 
poses, the  histories  reported  sufficed  to  throw  further  discredit  upon 
what  was  theoretically  pronounced  a  questionable  procedure. 

The  outcome  of  the  controversy  was  so  complete  a  victory  for  the 
Caesarean  school  that  in  France,  England,  Germany,  and  America 
most  writers  on  obstetrics  either  omitted  all  mention  of  symphysiotomy, 
or  referred  to  it  either  as  a  subject  for  invective  or  as  a  matter  of  his- 
torical interest. 

In  Italy  alone  symphysiotomy  never  fell  into  complete  disfavor,  but 
was  always  recognized  as  an  admissible  measure  in  the  treatment  of 
contracted  pelves.  In  the  table  of  Neugebauer,  compiled  from  the 
statistics  of  Morisani,  of  Harris,  and  of  Desforges,  of  the  136  cases 
known  to  liave  been  operated  uj)on  between  the  years  1770  and  1806, 
56,  or  about  two  fifths  of  the  entire  number,  occurred  in  Italy.  Be- 
tween the  years  1815  and  1841,  Galbiati  operated  18  times.  The  re- 
sults in  Italy  were  indeed  not  particularly  satisfactory.  Thus  in  the 
56  cases  22  mothers  were  known  to  have  recovered,  18  were  reported  to 
have  died,  and  in  16  the  issue  was  in  doubt;  16  of  the  children  were 
born  alive,  22  died,  and  in  18  cases  the  result  was  uncertain. 

In  1863,  Morisani,!  of  Naples,  published  a  memoir  on  the  pelvic 
contractions  and  the  indications  they  afford  at  the  time  of  birth,  in 

*  Vide  Die  Symphyseotomie  und  ihre  wissenschaftliche  Begriindung,  von  Dr. 
Wehle,  Arbeiten  aus  der  Koniglichen  Frauenklinik  im  Dresden,  189;J,  8.  3  and  9. 

t  Vide  Caruso,  Contribute  alia  pratica  della  siufisiotomia,  Annali  di  Ostetricia 
e  Ginecologia,  April,  1893  (foot-note  No.  x). 


SYMPHYSIOTOMY.  71 7 

which  he  endeavored  to  determine  by  experiments  on  the  cadaver  the 
mechanism  of  the  increase  of  the  diameters  of  the  superior  strait  after 
symphysiotomy,  and  the  average  increase  obtained.  As  a  result  of 
these  investigations  he  was  convinced  that,  in  spite  of  the  chissical  ob- 
jections to  the  operation,  the  gain  in  the  pelvic  space  was  real,  and 
tliat,  within  certain  limits,  to  be  determined  by  clinical  experience,  the 
operation  was  reasonably  devoid  of  risk. 

Between  July  25,  1858,  and  February  4,  18G5,  Harris  tells  us  there 
was  no  known  case  in  which  symphysiotomy  was  employed.  At  the 
latter  date  Professor  Bcllozi,  of  Bologna,  operated,  but  the  patient  suf- 
fered from  tuberculosis,  and  died  twelve  days  afterward  from  pneu- 
monia. On  January  5,  1866,  Morisani  performed  his  first  operation. 
Both  mother  and  child  were  saved.  This  success  marked  the  begin- 
ning of  a  new  era. 

At  the  meeting  of  the  International  Medical  Congress  in  London 
in  1881,  Morisani  was  able  to  publish  50  operations  that  had  been  per- 
formed in  Naples  between  1866  and  that  date,  with  the  saving  of  the 
lives  of  41  mothers  and  41  children.  It  seems  strange  now  to  recall 
the  slight  impression  these  results  then  made,  and  yet  they  were  all  the 
more  remarkable  as  at  the  time  of  this  report  aseptic  methods  were 
sparingly  practiced.  In  the  same  year  Novi,*  whose  name  stands 
hardly  second  to  that  of  Morisani  in  the  history  of  the  revival  of 
symphysiotomy,  published  an  important  memoir  on  the  same  subject 
of  a  statistical  and  clinical  nature.  In  1883,  Mangialli  f  in  Italy,  and 
our  own  Harris,^  in  two  memorable  papers  strove  to  further  awaken 
general  interest  in  what  they  regarded  as  a  coming  revolution.  Again, 
in  1886,  Morisani  made  a  report  of  the  cases  that  had  been  operated 
upon  in  Naples  between  1881  and  that  date.  They  were  18  in  num- 
ber. The  results  were  unfavorable  :  8  of  the  mothers  were  lost ;  5  of 
tlie  children  were  born  dead.  The  contrast  between  this  lamentable 
outcome  and  the  brilliant  contemporaneous  record  of  the  Caesarean  sec- 
tion was  too  striking.     Outside  of  Italy  the  battle  was  regarded  as  lost. 

In  the  month  of  October,  1891,  Spinelli  went,  at  the  suggestion  of 
Morisani,  to  Paris  to  place  before  the  medical  profession  of  France  the 
most  recent  achievements  of  the  Neapolitan  school  in  symphysiotomy. 
Between  1888  and  1891  he  was  able  to  report  a  succession  of  24  cases, 
with  the  recovery  of  24  mothers  and  the  saving  of  23  children's  lives. 
In  a  lecture  *  delivered  before  the  assembled  Paris   accoucheurs  he 

*  Novi,  La  Sinfisiotomia  refugiata  presso  la  Scuola  Napoletana.  Napoli,  1881. 

t  Mangialli,  Una  probabile  resurrezione  nel  campo  dell'  ostetricia  operativa, 
Annali  di  Ostetricia,  ecc„  1883,  p.  6  {vide  Caruso). 

X  Robert  P.  Harris,  A.  M.,  M.  D.,  The  Revival  of  Symphysiotomy  in  Italy,  The 
Am.  Journ.  of  the  Med.  Sciences,  Jan.,  1883. 

*  Spinelli,  Les  resultats  de  la  Symphyseotomie  antiseptique  a  I'Ecole  obstetri- 
cale  de  Naples,  Annales  de  Gynecologie,  Paris,  Janvier,  1893. 


718 


APPENDIX. 


demonstrated  the  operation  upon  the  cadaver.  He  taught  that,  thanks 
to  symphysiotomy,  a  full-terra  child  can  be  extracted  iu  a  pelvis  meas- 
uring not  less  than  two  inches  and  a  half  (sixty-five  millimetres),  and 
that  with  proper  antiseptic  precautions,  and  within  the  limits  indicated, 
the  operation  is  devoid  of  danger. 

Among  the  first  to  accept  the  new  doctrine  was  Pinard,*  who  on 
December  7,  1891,  delivered  at  the  Baudelocque  Maison  d'Accouche- 
nients  a  lecture  in  which  he  earnestly  and  eloquently  defended  sym- 
physiotomy. By  means  of  a  pelvic  section  he  furnished  a  most  strik- 
ing illustration  of  the  reality  of  the  pelvic  increase  consequent  upon 
the  division  of  the  symphysis,  and  at  the  same  time  he  expressed  his 
conviction  that  the  operation  was  not,  as  the  rule,  difficult  of  execution, 
and  that  it  could  be  performed  without  injuring  the  bladder  or  the 
peritoneum.  On  February  4,  1892,  he  performed  his  first  operation, 
which  ended  favorably  both  for  the  mother  and  the  child. 

In  March,  1892,  Charpeutier,  after  a  personal  visit  to  Naples,  fur- 
nished to  the  French  Academy  of  Medicine  an  admirable  digest  of  the 
subject  which  had  a  widespread  circulation.  In  April,  Caruso  f  con- 
tributed an  important  paper  containing  the  recent  Neapolitan  statis- 
tics, and  giving  practical  details  concerning  the  indications,  the  meth- 
ods of  operation,  and  the  care  of  patients  after  the  operation.  He 
declared  that  with  antiseptic  precautions  there  should  be  no  mortality 
from  section  of  the  symphysis,  and  that  in  the  case  of  a  fatal  result 
the  death  should  be  attributed  to  the  operator  rather  than  to  the  opera- 
tion. 

Finally,  general  interest  was  awakened  in  the  subject  in  America 
by  Harris's  J  article,  read  before  the  Gyniecological  Society  in  October, 
1891,  and  through  the  publication  of  a  successful  case  by  Professor  Jew- 
ett,«of  Brooklyn. 

Anatomy. — To  operate  intelligently  and  with  reasonable  assurance 
of  success  a  knowledge  of  the  anatomy  involved  becomes  a  matter  of 
prime  importance.  Fortunately,  following  the  visit  of  Spinelli  to 
France,  Faraboeuf,  Avho  became  greatly  interested  in  the  rehabilitation 
of  Sigault's  work,  entered  enthusiastically  upon  the  labor  of  supple- 
menting the  defective  and  vague  teachings  of  the  ordinary  text-books 
by  clear  and  definite  descriptions  of  the  structures  involved.    The  beau- 

*  Pinard,  De  la  Symphyseotomie. 

t  F.  Caruso,  contributo  alia  pratica  della  sinfisiotomia,  Annali  di  Ostetricia  e 
Ginecologia. 

X  Harris,  The  Remarkable  Results  of  Antiseptic  Symphysiotomy,  Gyna;cological 
Trans.,  1892. 

*  To  Professor  Jewett  belongs  the  honor  of  contributing  the  first  published  case 
of  symphysiotomy  in  America.  His  Vjore  date  of  September  'SO,  1892,  but  the  first 
actual  case  in  the  United  States,  according  to  Dr.  Harris,  was  one  operated  upon 
by  Dr.  Joel  0.  Williams  of  Denison,  Texas,  in  1880.  Both  mother  and  child  are 
still  livintr. 


SYMPHYSIOTOMY. 


719 


tiful  studies  of  the  eminent  Paris  professor  were  at  once  made  by  Pi- 
nard  and  Varnier  the  foundation  of  their  practice  in  the  Hopital  Baude- 
locque.  The  remarkable  triumphs  which  ensued  are  the  incentives 
which  prompt  me  even  at  some  length  to  place  them  at  the  disposition 
of  the  English-reading  medical  public* 

One  of  the  first  results  of  substituting  observation  for  deductive  rea- 
soning was  to  demonstrate  that  Matthews  Duncan  was  incorrect  in 
maintaining  that  the  sacral  articulation  slopes  backward  and  inward  in 
the  direction  of  the  median  line,  and  that  the  fact  that  the  sacrum  does 
not  under  pressure  drop  from  the  arch  is  due  to  the  sacro-sciatic  liga- 
ments which  hold  it  in  position  as  part  of  the  bony  ring.     On  the  cou- 


FiG.  233.— Transverse  pelvic  section  near  the  superior  strait,  pubic  bones  separated  by  a  finger's 
breadth  :  experiment  of  Faraboeuf,  showing  that  the  sacrum  actually  forms  akey  to  the 
pelvic  arch,  and  is  not  simply  held  in  place  by  the  ligaments.  If  a  longitudinal  section  be 
made  through  the  sacrum  in  fi-ont  of  the  li2:aments,  the  resected  portion  remains  solidly  in 
situ  until  a  considerable  degree  of  pubic  separation  has  been  effected.    (Faraboeuf.) 


trary,  a  series  of  sections  through  the  sacro-iliac  articulations  at  differ- 
ent points,  made  parallel  to  the  pelvic  brim,  sufficed  to  demonstrate 
that  the  shape  of  the  sacral  articular  surface  is  such  that  the  sacrum, 
in  its  insertion  between  the  ilia,  in  reality  forms  a  keystone  to  the  pel- 
vic arch.  In  a  striking  experiment  (Fig.  233)  Faraboeuf  has  shown 
that  if  a  frontal  section  of  the  sacrum  be  made  from  above  downward 
and  in  front  of  the  ligamentous  attachments,  the  anterior  segment,  so 
long  as  the  pelvic  ring  is  closed,  is  held  tightly  in  place  by  the  iliac 

*  The  privilege  to  use  the  accompanying  illustrations,  which  have  been  to  me, 
invaluable  in  studying  the  operation  of  symphysiotomy,  I  owe  to  the  courtesy  of 
Professor  Faraboeuf. 


720 


APPENDIX. 


'"■  ^ -S';;ris'„i?Serr™f„z»„t;LVa"i^^^^^^^^ 


SYMPHYSIOTOMY. 


721 


pressure  alone.  The  loss  of  the  support  due  to  this  pressure  must  be 
borne  in  mind  after  division  of  the  symphysis  and  in  cases  where,  after 
symphysiotomy,  the  pubic  union  remains  incomplete. 

The  ligaments  by  which  the  fastening  of  the  pelvic  bones  is  secured 
posteriorly  are  short,  strong,  and  inelastic.  They  run  for  the  most  part 
in  a  transverse  direction.  Passing  from  above  downward,  the  first  in 
order  is  the  ilio-lumbar,  which  extends  from  the  transverse  process  of 
the  lower  lumbar  vertebra  outward  and  backward  and  is  inserted  into 


Fig.  235. — The  hollow  of  the  auricular  surface  is  seen  to  follow  in  a  circle,  the  center  of  which  is 
situated  at  the  first  tubercuUim  conjngatum.  and  is  indicated  in  black.  In  fresh  specimens 
many  fibrous  bundles  pass  f ro'Ti  the  tuberosity  of  the  ilium  to  the  joint,  forming  the  liga- 
mentuin  vagum  or  axillary  ligament. 


the  iliac  crest.  It  fulfills  the  function  of  hindering  the  disposition  of 
the  last  lumbar  vertebra  to  glide  forward  over  the  inclined  plane  of  the 
base  of  the  sacrum.  Tlie  most  important  bands  traverse  the  sacro- 
iliac articulation.     They  are  arranged  in  three  groups  : 

First.  A  ligament  passes  from  the  transverse  process  of  the  sacrum 
across  the  upper  border  of  the  auricular  surface  to  the  tuberosity  of  the 
ilium,  not  far  from  the  iliac  crest. 

Second.  Below  the  above  the  sacral  surface  offers  a  number  of 
tuberosities  formed  during  the  developmental  period  by  the  fusion  of 
the  sacral  transverse  processes,  and  by  the  junction  of  the  sacral  verte- 
46 


T22 


APPENDIX. 


br£e.  Each  process  separates  into  an  ascending  and  descending  branch, 
which  unites  with  corresponding  branches  above  and  below  to  circum- 
scribe the  sacral  foramina.  The  tuberosity  thus  formed  at  the  linea 
transversa  between  the  first  and  second  sacral  vertebra  is  situated  at  a 
point  near  the  middle  of  the  auricular  surface.  It  looks  upward,  out- 
ward, and  backward,  and  furnishes  attachments  to  a  great  number  of 


Fig.  236.— Lateral  view  of  sacrum  :  t,  the  first  sacral  transverse  process  :  1,  2.  and  3.  the  tuber- 
cula  conjupata.  The  line  A  represents  the  axis  about  which  the  ilium  turns  after  symphys- 
iotomy.   The  line  d  represents  the  plane  of  the  superior  strait. 


bands  (the  ligamentum  vagum),  varying  in  size,  in  tliickness,  and  in 
direction,  which  are  distributed  to  a  pyramidal  eminence  on  the  inner 
surface  of  the  iliac  tuberosity, 

TJiird.  The  tuberosity  between  the  second  and  third  vertebra  cor- 
responds to  the  lower  border  of  the  auricular  surface.  It  looks  toward 
the  internal  surface  of  the  posterior  superior  spinous  process,  to  which 
it  is  attached  by  a  short,  thick  ligament  named  by  Farabwuf  the  liga- 
ment of  Zaglass. 

Each  auricular  surface  forms  the  arc  of  a  circle  hollowed  upon  the 
sacral  and  in  relief  upon  the  iliac  side.  The  smooth  surfaces  of  the 
articulations  covered  with  cartilage  permit  a  restricted  movement  of 
rotation  (Fig.  234).  The  center  around  which  this  movement  takes 
place  is  situated  in  the  vicinity  of  the  first  sacral  tuberosity,  the  liga- 
ments at  which  point  have,  in  consequence,  sometimes  been  termed 


SYMPHYSIOTOMY. 


723 


"axillary,"  but  the  irregular  distribution  of  the  ligamental  bauds  has 
led  Farabceuf  to  compare  the  ilium  to  a  button  badly  sewed  to  the 
sacrum. 

The  extreme  degree  of  forward  rotation  of  the  promontory  is  pro- 
duced in  a  person  slightly  bent  and  carrying  a  heavy  weight  upon  the 


Fig.  237.— Separation  of  the  pubis  after  symphysiotomy  of  2^  inches  ;  detachment  of  the  peri- 
osteum from  the  ilium  at  d  equals  on  the  average  If  inches  :  s.  /.,  relaxation  of  the  sacro- 
iliac ligaments  ;  B,  transverse  section  throug-h  the  first  sacral  vertebra  of  an  infant  three 
months  old  ;  n,  neural  portion  ;  c,  costal  portion. 


shoulders.  In  an  acrobat  balanced  upon  a  trapeze,  with  the  cross-bar 
beneath  the  loins,  with  the  lower  limbs  hanging  downward,  and  with 
the  trunk  acting  upon  the  sacrum,  the  promontory  is  moved  backward 
and  the  coccyx  is  rotated  forward.  In  the  former  instance  a  narrow- 
ing, in  the  latter  a  widening,  of  the  conjugata  follows. 


f24 


APPENDIX. 


Clinically,  similar  conditions  may  be  ijroducod  in  the  recumbent 
posture  by  acting  upon  the  ilia  (the  long  arms  of  the  lever).  Thus, 
by  flexing  the  thighs  so  as  to  touch  the  chest  the  ilia  are  rotated  up- 
ward and  the  conjugate  is  shortened,  or  by  placing  the  patient  with 
the  hips  at  the  edge  of  the  bed  or  table,  and  with  the  thighs  hanging 


Fig  238 —With  the  njijht  thigh  hel.1  forciblj  .n  flpxion  and  adduction,  the  right  ilium  is  made 
fast  to  the  sacrum.  By  the  abduction  of  the  left  leg  the  disjunction  of  left  sacroiliac  artica 
lation  is  then  accomplished. 


downward  (Walcher's  position),  the  ilia  are  made  to  move  in  an  oppo- 
site direction.  As  the  pubis  rotates  in  the  direction  of  the  coccyx  the 
antero-posterior  diameter  of  the  brim  is  lengthened,  with  a  correspond- 
ing diminution  in  that  of  the  excavation  and  of  the  outlet.  The  dis- 
placement communicated  to  the  pubic  end  of  the  lever  by  these  methods 
amounts  to  very  nearly  an  inch,  while  that  at  the  sacro-iliac  joint  barely 
equals  one  fourth  of  that  amount.*  The  actual  gain  to  be  derived  from 
position,  therefore,  Farabonif  regards  as  insignificant,  and  yet  when 
dealing  with  the  contracted  pelvis  previous  to  engagement  the  smallest 
increase  at  the  superior  strait  is  deemed  precious  by  the  bedside  at- 
tendant. 

After  section  of  the  symphyses  each  lateral  wall  of  the  pelvic  exca- 
vation turns  outward,  as  upon  a  hinge,  around  the  sacrum.  The  axis 
of  this  movement  descends  obliquely  downward  (Fig.  2.3G)  and  some- 
what inward  in  a  line  touching  the  upper  and  lower  cornua  of  the 
auricular  surfaces.  The  posterior  ilio-transverso  ligaments  as  a  whole 
are  not  affected  by  the  separation  of  the  pubic  bone.    Only  a  few  fibers 

*  The  moYement  at  the  pubis  ParabcBuf  estimates  approximately  at  twenty  mil- 
liraetres,  and  that  at  the  pacro«jliao  point  at  about  fivo  millimetres. 


SYMPHYSIOTOMY. 


725 


of  the  ligamentum  vagum  situated  in  front  of  the  axis  are  put  upon 
tlie  stretch,  and  the  exercise  of  a  little  force  may  be  required  to  com- 
l)lete  their  rupture. 

The  fibers  of  the  periosteum  which  constitute  the  anterior  sacro- 
iliac ligaments  are  the  first  to  feel  the  effect  of  the  disjunction  at  the 
pubis,  especially  those  fibers  which  are  farthest  removed  from  the  axis 
— i.  e.,  from  the  cornua  of  the  auricular  surfaces:  the  separation  be- 
gins, therefore,  at  the  linea  innominata,  and  thence  passes  a  short 
distance  outward.*  It  is  confined  to  the  ilia  alone.  Above  and  below 
it  is  limited  to  the  vicinity  of  the  extremities  of  the  articulation  (Fig. 
2'M).  The  stripping  up  of  the  periosteum  may,  however,  be  increased 
if  at  the  beginning  of  rotation  a  tuberosity  of  the  ilium  upon  either 
side  comes  into  contact  with  a  bony  projection  upon  the  sacrum. 

Experience  shows  that  the  pubic  bones  as  they  separate  follow  very 
nearly  the  plane  of  the  superior  strait.  The  sacro-pubic  distance  is 
increased  until  a  point  opposite  the  sacro-iliac  joint  is  reached.    As  the 


Fig.  239. — Symmetric  separation  after  symphysiotomy.  The  sacro-pubic  distance  is  increased 
by  the  outward  rotation  of  the  iliac"  The  chief  gain  is  due,  however,  to  the  projection  of 
the  parietal  boss  between  the  pubic  bones.  When  the  separation  of  the  latter  equals  SJ 
inches,  the  available  utero-posterior  space  is  augmented  by  more  than  an  inch. 


axis  of  this  rotation  has  an  oblique  direction,  a  marked  descent  of  the 
pubic  extremities  results.  To  use  a  familiar  illustration  of  Faraboeuf, 
the  movement  is  like  that  of  the  door  of  a  street  lamp  upon  hinges 
attached  to  a  sloping  side.  An  asymmetrical  separation  at  the  sacro- 
iliac articulations  is  indicated  when  the  lateral  halves  of  the  pelvis 
occupy  different  planes.     An  exaggerated  difference  of  level  in  the 

*  "  A  few  centimetres  "  (Faraboeuf). 


726  APPENDIX. 

pubic  bones,  at  times  amounting  to  an  inch  and  a  half,  may  be  pro- 
duced by  forcibly  flexing  one  limb  while  the  other  remains  extended. 

The  weight  of  the  flexed  thiglis  in  abduction  suffices  ordinarily  to 
so  far  overcome  the  resistance  offered  by  the  sacro-iliac  fastenings  as  to 
permit  a  separation  of  an  inch  at  the  pubis.  Beyond  that  point  a  cer- 
tain amount  of  force  may  be  requisite  to  strip  up  the  periosteum  and 
to  rupture  the  fibers  of  the  ligamentum  vagum,  which  are  situated  in 
front  of  the  axis  of  iliac  rotation.  If  by  mischance  the  outward  pressure 
applied  to  the  knees,  by  means  of  which  the  sacro-iliac  separation  is 
produced,  acts  unequally  upon  the  two  sides,  furtlier  separation  upon 
the  side  where  it  is  already  sufficient  may  be  arrested  by  forcible  adduc- 
tion and  flexion  of  the  thigh  (Fig.  238).  This  mananivi-e  reapplies  the 
ilium  to  the  sacrum,  and  enables  the  operator  to  employ  forcible  abduc- 
tion upon  the  other  knee  until  a  symmetrical  separation  has  been 
attained. 

The  advantages  to  be  won  from  symphysiotomy  are  derived  from 
three  sources : 

First.  The  increase  of  the  sacro-pubic  distance.  In  a  pelvis  meas- 
uring two  and  a  half  inches  in  the  conjugate  the  gain,  according  to  the 
measurements  of  Farabanif,  when  the  separation  of  the  pubic  bones 
(Fig.  339)  amounts  to  two  and  a  quarter  to  two  and  three  quarter 
inches,  is  very  nearly  a  half  inch. 

Second.  In  the  engagement  and  descent  of  the  head  a  segment  of 
the  latter  occupies  the  space  between  the  separated  pubic  bones.  The 
resultant  gain  is  dependent  upon  the  width  of  the  gap  and  the  convex- 
ity of  the  child's  head.  Faraboeuf  estimates  this  roughly,  with  the  an- 
terior parietal  boss  occupying  an  interval  measuring  from  two  to  two 
and  a  quarter  inches,  at  three  quarters  of  an  inch. 

The  advantage  from  these  two  sources,  therefore,  should  be  placed 
at  very  nearly  an  inch  and  a  quarter.* 

Third.  The  forced  extension  of  the  thighs  adds  a  few  lines  to  the 
superior  strait,  but  this  addition  is  at  the  expense  of  the  pelvic  cavity. 
In  estimating  the  justifiability  of  symphysiotomy,  therefore,  it  is  neces- 
sary for  this  reason  to  take  into  account  not  only  the  size  of  the  conju- 
gate, but  the  curve  of  the  sacrum,  and  the  distance  between  inter- 
mediate points  situated  upon  the  inner  surface  of  the  pubis  and  of  the 
sacrum. 

In  the  ordinary  flattened  pelvis  after  section  the  spontaneous  sepa- 
ration of  a  few  lines  which  ensues  is  followed  by  the  descent  of  the 
posterior  frontal  bone  and  ear,  due  to  the  sinking  of  the  pubis,  upon 
which  the  anterior  frontal  bone  rests.  With  forced  separation  the 
latter  sinks  to  the  level  of  the  boss,  and  the  posterior  car  descends 

*  In  minor  degrees  of  pelvic  contraction  the  relative  advantage  is  slightly  less- 
ened. 


SYMPHYSIOTOMY. 


T27 


beneath  the  promontory,  to  which  the  posterior  frontal  bone  is  ap- 
plied. Engagement  is  then  accomplished  by  the  rotation  of  the  head 
around  the  promontory,  by  means  of  which  the  entrance  of  the  an- 
terior cranial  surface  into  the  pelvic  cavity  is  effected.  But  this 
mechanism  is  dependent  upon  a  sufficiency  of  the  sacral  curve.* 

It  is  important,  furthermore,  to  remember  that  in  cases  where  the 


Fig.  240.— ShowinK  the  fusion  of  the  liga- 
mentuin  arcuatum  and  the  fibrous 
covering. 


Fio.  241.— The  section  is  made  a  little  be- 
low the  upper  border,  and  displays  the 
bony  epiphysis  on  each  side. 


adjustment  of  the  head  to  the  pelvic  space  is  close  the  entrance  of  the 
head  at  the  brim  may  be  facilitated  by  the  backward  rotation  of  the 
promontory  produced  by  the  extension  of  the  thighs.  On  the  other 
hand,  when  the  engagement  is  interfered  with  by  the  contact  of  the 
posterior  parietal  surface  with  the  sacrum,  a  utilizable  gain  in  the  me- 
dian pelvic  diameter  may  be  realized  by  the  movement  of  counter- 
rotation  jiroduced  by  flexing  the  thighs  and  lifting  the  extremities  of 
the  pubic  bones. 

Finally,  it  should  be  remembered  that  the  increase  of  space  result- 


K  **  ^  f  *.  "^^,'5 


Fig.  242. — Transversf  and  sac^ittal  sections  through  the  symphysis  of  a  yonng  woman.    The 

fjosterior  ridge  is  short,  but  the  periosteum  is  literally  packed  With  bundles  of  fibro-Oarti- 
age,  pursuing  for  the  most  part  a  horizontal  direction. 

ing  from  symphysiotomy  is  not  confined  to  the  antero-posterior  diame- 
ter, but  extends  to  iill  the  dimensions  of  the  pelvis. 

The  Symphysis. — The  bones  of  the  pubis  are  connected  by  a  plug 

*  Farabojiif  estimates  that  in  a  pelvis  measuring  two  and  a  half  inches  (sixty 
millimetres)  antero-posteriorly  the  extraction  of  the  child  after  symphysiotomy  be- 
comes extremely  difficult,  where  the  median  pelvic  diameter  is  not  three  to  four 
fifths  of  an  inch  (fifteen  to  twenty  millimetres)  longer  than  at  the  brim. 


(28 


APPENDIX. 


composed  of  pure  cartilage  where  it  comes  in  contact  with  the  surfaces 
of  the  bones,  and  of  fibro-cartilage  toward  its  center.  Both  the  inter- 
vening plug  and  the  ends  of  the  bones  are  enveloped  in  a  periosteal 
covering,  re-enforced  by  tendinous  attachments  from  the  adjacent 
muscles. 

During  early  life  the  pubic  bones  at  the  symphysis  are  convex. 


Fig.  243.— Transverse  section  of  the  external  genital  organs  of  the  woman  close  to  the  lower 
anterior  surface  of  the  pubes  and  symphysis:  rf.  insertions  of  the  recti  muscles;  p.  inser- 
tion of  pyramidalis.  The  clitoris  and  its  suspensory  ligament  have  been  cut  away  ;  the 
fossa,  and  the  longitudinal  ligaments  are  exposed  ;  the  rami  of  the  clitoris  are  cut  across, 
and  the  opening  beneath  the  symphysis  is  brought  into  view. 


The  cartilage  which  serves  for  their  growth  and  nourishment  is  thick 
and  hyaline.  After  puberty,  however,  there  forms  in  the  cartilage  at 
a  point  which  is  destined  later  to  become  the  angle  of  the  pubis  a  bony 
process  which  gradually  extends  to  the  upper  border  of  the  pubic  body, 
to  its  anterior  surface,  and  to  the  surface  of  the  symphysis  itself. 


SYMPHYSIOTOMY. 


729 


As  a  consequence  of  the  tardy  growth  of  tliis  process  it  is  practi- 
cable, in  a  parturient  woman  under  twenty,  to  make  an  incision  either 
directly  in  the  median  line  or  a  third  of  an  inch  to  the  side  of  the 
median  line  in  the  hyaline  cartilage,  which  still  separates  the  rounded 
epiphysis  from  the  pubic  border.  At  fl  later  period,  after  the  union  of 
the  epiphysis  and  the  body  is  completed,  the  bony  surfaces  are  no 
longer  rounded,  but  are  uneven  and  traversed  by  grooves  and  ridges. 
These,  though  the  intervening  space  is  in  reality  ample,  have  a  tend- 
ency to  catch  the  knife  of  the  unwary  operator,  and  thus  to  give  rise  to 
fables  regarding  the  bony  anchylosis  of  the  symphysis  during  the  child- 
bearing  period. 

The  solidity  of  the  pelvis  is  due  not  so  much  to  the  fibro-cartilage 


i;\iiiiiiiiiiii(!iii(!ii;i(,;;'///',7.' 


Fig.  244. — Median  section  through  the  fibro-cartilaginous  plug  between  the  pubic  bones.  The 
flbro-tendinous  covering  is  thin  behind,  where  two  subjacent  synovial  cavities  may  be  no- 
ticed— thick  above  at  the  attachment  cf  the  adminiculum  (a)  and  in  front  at  the  insertion  of 
the  recti  {D}  and  pyramidal  (p)  muscles  :  very  thiclc  below  where  it  forms  the  ligamentura 
arcuatum. 


at  the  pubic  articulation  as  to  the  glistening  pearly  fibers  by  which  the 
cartilage  is  enveloped  and  re-enforced. 

Upon  the  posterior  surface  the  prominence  which  marks  the  line  of 
bony  union  between  the  pubic  bones  is  covered  by  tlie  periosteum. 
This  latter,  at  the  upper  portion  of  the  symphysis  behind  the  recti 
muscles,  is  strengthened  by  the  access  of  fibers  from  distant  sources, 
as,  for  instance,  from  those  which  border  the  pubic  crests.  Below, 
beneath  the  pubic  arch,  it  forms  the  ligamentum  arcnatum.  Ante- 
riorly the  symphysis  is  increased  in  thickness  by  the  accession  of  a  vast 
number  of  tendinous  elements  which  intercross  at  the  median  line. 

When  an  incision  is  made  through  the  adipose  tissue  of  the  mons 
veneris,  and  the  divided  surfaces  are  drawn  well  apart,  the  operator 
exposes  laterally  the  attachments  of  the  muscles  of  the  thigh  to  the 
bony  ridges  which  border  the  symphyseal  space.     Overlying  these  are 


rso 


APPENDIX. 


two  longitudinal  bands  derived,  for  the  most  part,  from  the  external 
pillars  o'f  the  inguinal  ring.  Above,  the  internal  pillars  cross  at  the 
median  line  and  are  attached  each  to  the  bony  ridge  upon  the  opposite 
side.  Below,  at  a  variable  distance  from  the  arch,  the  filaments  which 
form  the  suspensory  ligaments'of  the  clitoris  are  brought  into  view. 
Between  the  longitudinal  bands  a  grooved  depression,  which  attains  its 


Fig.  245.— Dpep  portions  of  tlie  vulvar  region— symphysis,  clitoris,  bulb,  lower  layer  of  the  pni- 
neal  fa.scia.  The  left  ramus  of  the  clitoris  has  been  detacheri  from  the  arcli  "and  carried  to 
the  right.  The  left  bulb  has  been  removed.  The  excision  of  the  left  half  of  the  suspensoiy 
ligament  brings  into  view,  beneath  the  arch,  the  cellular  layer  in  which  are  located  the 
veins  of  the  neck  of  the  bladder,  of  the  urethra,  and  of  the  clitoris. 


maximum  width  and  depth  on  a  line  with  the  arch,  may  be  felt  by  the 
finger. 

The  flattened  tendon  of  each  rectus  muscle  is  attached  to  the  an- 


SYMPHYSIOTOMY.  73I 

terior  surface  of  the  pubis  below  the  upper  border.  This  distance  is 
greatest  at  the  median  line,  where  it  may  reach  a  half  inch  or  more. 
The  tendon  is  covered  by  the  pyramidal  muscle.  The  external  half  is 
fiat,  and  is  attached  in  front  of  the  upper  border  of  the  pubis  upon  its 
own  side.  The  inner  half  passes  downward  for  a  somewhat  greater 
distance  without  fusing  with  the  fascial  covering  of  the  symphysis.  It 
tlien  begins  wholly  or  in  part  to  adhere  and  to  intercross  with  the  ten- 
don of  the  opposite  side.  At  a  lower  point  its  fibers  separate  and  be- 
come interwoven  with  the  transverse  fibers  of  the  underlving  tendi- 
nous  structures,  and  finally  descend  to  form  insertions  en  echelon  into 
the  bony  ridge  opposite  the  side  from  which  they  had  their  origin. 

When  the  recti  are  separated  there  is  often  found  beneath  a  little 
fat  a  small  triangular  body,  the  adminiculum,  attached  by  its  base  to 
the  upper  border  of  the  symphysis  and  of  the  pubic  bones.  Its  apex  is 
confounded  with  the  linea  alba.  It  receives  fasciculi  from  the  recti 
muscles,  to  which  it  serves  as  a  tendon.  Its  base  is  riddled  by  small 
perforating  vessels.  This  body  may  furnish  a  certain  amount  of  re- 
sistance when  an  attempt  is  made  to  pass  the  finger  behind  the  sym- 
physis. 

After  section  of  the  mons  veneris  the  operator  has  therefore  to  cut 
through — 

1.  The  fibro-tendinous  coating  (perichondi-ium),  anteriorly  thick 
and  complex  in  structure,  posteriorly  composed  of  jieriosteum  alone. 
The  latter  is  thick  in  its  upper  portion.  It  can  be  reached  only  by  di- 
viding the  space  between  the  recti  muscles  and  the  linea  alba  and  after 
breaking  through  the  adminiculum. 

2.  The  fibro-cartilaginous  plug,  thick  above  and  below  and  in 
front,  where  it  is,  for  the  most  part,  confounded  with  the  perichon- 
drium ;  behind  it  is  narrowed  by  the  approximation  of  the  pubic 
bones. 

Tlie  Relations  of  the  Symphysis  to  the  Adjacent  Pelvic  Organs. — 
It  will  be  remembered  that  in  ordinary  labor  the  head,  in  its  transit 
through  the  parturient  canal,  stretches  the  levator  and  pushes  back 
the  coccyx,  and,  as  it  passes  through  the  vulvo-vaginal  outlet,  forcibly 
dilates  the  ischiatic  layers  of  the  perineal  fascia.  But  after  symphysi- 
otomy the  head  moves  forward  to  profit  by  the  gap  in  the  bony  ring. 
A  strain  is  thereby  placed  upon  the  anterior  vaginal  wall,  which,  unless 
met  by  some  counter-support,  may  endanger  its  integrity.  Below,  at 
the  vulva,  the  separation  of  tlie  bones  is  limited  somewhat  by  the  crura 
of  the  clitoris,  by  the  fascia  in  front  of  the  urethra,  and  perhaps  by  the 
pubic  attachments  of  the  bladder.  When  the  tension  to  which  these 
structures  are  exposed  becomes  excessive,  they  are  liable  to  give  way, 
and  an  extensive  laceration  of  the  vagina  to  the  side  of  the  urethra 
may  ensue.  For  this  reason  a  careful  watch  should  be  kept  upon  the 
space  between  the  pubic  bones,  and,  either  by  the  hands  of  assistants 


^-o9  APPENDIX. 

or  by  instrumental  means,  the  gap  should  not  be  allowed  to  exceed  the 
narrowest  limits  rendered  necessary  for  the  passage  of  the  child. 

The  crura  of  the  clitoris  are  solidly  attached  to  the  inner  surfaces 
of  the  ischio-pubic  rami,  and  are  adherent  to  the  lower  layer  of  the 
pelvic  floor,  across  which  are  distributed  the  terminal  branches  of  the 
pubic  artery — viz.,  the  arteries  of  the  corpora  cavernosa,  the  urethral 
artery,  and  the  dorsal  of  the  clitoris,  all  vessels  of  insignificant  size. 


Fig.  246.— The  vessels  upon  the  pelvic  surface  of  the  symphysis :  on  the  left  Ride  the  arteries 
alone  have  been  preserved  :  on  the  right  side  both  veins  and  arteries  are  visible.  The  blad- 
der is  drawn  downward  by  two  hooks,  puffing  the  pnho-vesical  liiraments  on  the  stretch  on 
each  side  of  the  median  fossa,  into  which  penetrate  the  two  anterior  vesical  arteries, 
branches  of  the  pudic  artery. 


The  cavernous  tissues  are  enveloped  in  a  fibrous  sheath  which  is  re- 
duced to  a  minimal  thickness  at  the  long  and  narrow  point  of  contact 
between  the  crura  and  the  pubic  arch,  where,  indeed,  the  albuginea  is 
apparently  replaced  by  the  periosteum.  The  adhesions  of  the  fibrous 
sheaths  to  the  periosteum  are  very  firm,  and  extend  upward  to  a  vari- 
able extent  along  the  ridges  which  serve  as  the  points  of  insertion  to 


SYMPHYSIOTOMY. 


733 


the  adductor  muscles.  In  the  fossa  between  the  ridges  the  clitoris  is 
free.  The  crura  ascend  and  unite  to  form  the  body  at  a  variable 
height,  sometimes  on  a  level  with  the  arch,  sometimes  above  the  mid- 
dle of  the  symphysis. 

When  an  incision  is  made  at  the  mons  veneris  and  the  divided  tis- 
sues are  drawn  well  to  the  side  by  retractors,  the  aggregation  of  lamellae 
and  of  filaments  known  as  the  median  suspensory  ligament  of  the  cli- 


FiG  247  -Anterior  siirface  of  inflated  bladder,  showing:  the  dor.=al.  the  cayernoiis.  the  urethral, 
and  anterior  vesical  veins,  branches  of  the  internal  pudic.  The  pin  indica  es  the  d.vulmK 
fine  between  the  two  currents-viz..  the  upper  pelvic,  above  the  levator  am,  and  the  lower 
perineal,  on  the  uro-genital  (perineal)  floor. 

toris  is  exposed  to  view.  These  are  inserted  into  the  dorsum  of  the 
clitoris  and  into  the  unattached  portions  of  the  crura.  The  clitoris 
and  the  suspensory  ligament  occupy  the  symphyseal  fossa,  which,  at  its 
base  above  the  pubic  arch,  measures  about  three  quarters  of  an  inch  m 
width. 


'34 


APPENDIX. 


If  the  suspensory  ligament  is  cut  across,  and  the  clitoris  is  drawn 
downward,  the  pubic  arch  is  exposed. 

The  vessels  are  imbedded  in  a  fibro-cellular  covering,  by  means  of 
which  the  vesical  veins  are  applied  to  the  bladder,  the  urethral  to  the 
urethra,  and  the  dorsal  to  the  clitoris.  These  vessels  therefore  accom- 
pany these  organs  when  the  latter  are  detached  from  the  pubis. 

The  veins  upon  the  inner  pubic  surface,  though  ten  to  twenty  times 


FiQ.  248.— The  separated  pubic  bones,  showing  veins  behind  sj-mphysis  and  veins  of  the  bladder. 


larger,  can  distribute  only  the  blood  received  from  the  arteries.  TV'hen 
the  venous  circulation  has  been  impeded  by  labor,  pubic  section  may 
be  therefore  attended  temporarily  by  the  outflow  of  the  imprisoned 
blood,  but  the  apparent  haemorrhage  is  readily  controlled  by  the  tam- 
pon. After  the  veins  are  once  emptied  they  can  only  convey  the  blood 
carried  to  them  by  the  arteries. 


SYMPHYSIOTOMY.  Y35 

Tliere  are  no  vessels  in  the  fibro-cartilage  of  the  symphysis.  In  the 
periosteal  covering  there  are  only  capillaries.  Upon  the  posterior  sur- 
face of  the  pubic  bones  the  vessels  are  small  and  need  not  occasion  con- 
cern to  the  operator. 

The  pubis  is  about  two  inches  in  height.  The  thickness  is  very 
nearly  an  inch  when  the  posterior  eminence  which  marks  the  line  of 
union  of  the  pubic  bones  is  pronounced  (Fig.  242).  The  eminence  is 
most  marked  near  the  center,  and  diminishes  toward  the  upper  and 
lower  borders.  At  the  latter  points,  indeed,  the  feeling  communicated 
to  the  finger  when  introduced  from  the  front  is  rather  that  of  a  de- 
pression. 

Operation. — The  operative  methods  employed  in  pubic  section  vary, 
for  the  most  part,  in  minor  details.  The  results  obtained  by  Morisani 
and  the  Italian  school  place  their  rules  of  procedure  in  the  front  rank 
as  regards  importance.  To  avoid  confusion,  however,  I  have  thought  it 
best  to  lay  especial  stress  upon  the  scheme  formulated  by  Faraboeuf 
and  based  upon  his  careful  anatomical  investigations.  It  differs 
chiefly  in  precision  from  tiiat  devised  by  the  Neapolitan  school.  It 
leaves  nothing  to  chance,  but  serves  at  each  step  as  a  guide  and  a 
warning.  Moreover,  its  value  has  been  amply  sustained  by  the  clinical 
experiences  of  Pinard  and  of  Varnier  at  the  Hopital  Baudelocque  in 
Paris. 

If  consistent  with  the  safety  of  the  mother  and  child,  it  is  impor- 
tant that  labor  be  allowed  to  continue  until  softening,  and,  as  far  as 
possible,  dilatation  of  the  utero-vaginal  canal  is  secured.  Where  a 
speedy  ending  is  of  importance  the  preparatory  stage  may  be  furtherel 
by  means  of  the  Barnes  dilators  or,  as  recommended  by  Pinard  and 
Varnier,  by  the  Champetier  bag.  It  must  be  remembered  that  when 
the  support  furnished  by  the  pelvic  bones  in  front  has  been  lemoved, 
the  liability  to  laceration  of  the  anterior  soft  structures,  if  forceps  or 
version  is  employed,  is  greatly  increased  by  rigidity  of  the  parturient 
canal.  Moreover,  the  life  of  the  child  is  additionally  imperiled — a 
matter  of  special  importance  in  an  operation  the  object  of  which  is  the 
saving  of  infant  life. 

Before  commencing  the  operation  the  patient  should  take  a  full 
bath,  the  bowels  should  be  cleared  out  by  an  enema,  and  the  bladder 
should  be  emptied.  In  all  cases  the  pubes  and  labia  should  be  shaved  ; 
the  abdomen,  the  external  parts,  the  vestibulum,  the  anus,  and  the" 
internal  surface  of  the  thighs  should  be  cleansed  by  scrubbing  with 
soap  and  water  and  washing  with  sterilized  water,  with  alcohol,  and 
with  a  solution  of  corrosive  sublimate.  It  should  not  be  forgotten 
that  the  patient,  the  armamentarium,  and  the  personnel  in  symphys- 
iotomy require  aseptic  precautions  as  careful  and  minute  as  those 
resorted  to  in  abdominal  surgery.  The  operation  demands  assistants 
familiar  with  surgical  methods,  and  who  have  studied  the  steps  of  the 


^gg  APPENDIX. 

operation.  The  chance  successes  in  tenement-houses  and  amid  un- 
favorable surroundings  have  contributed  to  a  feeling  of  unwarranted 
security  on  the  part  of  many  operators.  The  brilliant  records  that 
have  been  made  in  the  past  have,  however,  been  limited  to  a  small 
number  of  conscientious  students  of  the  subjects.  It  should  be  re- 
membered that  the  general  statistics  up  to  date  exhibit  a  heavy  mor- 
bidit}^  and  that  one  in  nine  cases  where  symphysiotomy  has  been  per- 
formed has  ended  fatally. 

At  the  time  of  the  operation  the  patient  should  be  placed  in  the 
dorsal  position,  with  the  hips  drawn  to  the  edge  of  the  operative  table, 
and  with  the  thighs  flexed  and  moderately  everted.  The  latter  should 
be  held  by  two  reliable  assistants.  The  inopportune  dropping  of  a 
limb  after  symphysiotomy  has  been  the  occasion  of  the  violent  separa- 
tion of  a  sacro-iliac  joint.  The  operator  sits  or  stands  between  the 
thighs  of  the  patient.  An  expert  is  needed  to  adininister  the  anaes- 
thetic, a  nurse  or  physician  conversant  with  the  methods  of  treatment 
employed  in  the  asphyxia  of  new-bora  infants  should  be  in  readiness, 
and  to  promote  dispatch  an  assistant  is  desirable  to  pass  instruments, 
to  aid  with  the  ligatures  and  dressings,  and  to  supervise  aseptic  meas- 
ures. 

In  determining  the  situation  of  the  symphysis,  it  should  be  remem- 
bered that  the  line  of  bony  union  is  continuous  with  the  rima  vulva', 
the  meatus,  and  the  clitoris.  Any  variation  in  the  direction  of  the 
symphysis  is  communicated  to  these  organs.  The  spines  should  be 
located  with  the  finger,  and  the  upper  border  of  the  symphysis  should 
be  marked  for  future  guidance.  A  line  should  likewise  be  drawn 
transversely  below  to  indicate  the  situation  of  the  ligamentum  arcua- 
tum,  which  is  easily  recognized  by  the  finger  through  the  vestibulum 
below  the  clitoris,  or,  externally,  to  the  side  of  the  clitoris  through  the 
skin.  The  clitoris,  as  has  been  already  stated,  is  a  longitudinal  land- 
mark, but,  as  it  is  attached  at  variable  levels  in  different  subjects,  is 
not  a  guide  of  latitude.  Faraboeuf  recommends  the  tincture  of  iodine 
as  a  clean  agent  for  tracing  the  upper  and  lower  symphyseal  bound- 
aries. 

During  the  incision  the  index  and  thumb  of  the  left  hand  should 
be  employed  to  put  the  tissues  uj)on  the  stretch.  This  is  especially 
necessary  if  the  incision  is  to  be  downward.  The  primary  incision 
should  be  about  three  inches  long,  beginning  an  inch  and  a  half  above 
the  pubis  and  extending  downward  to  the  line  previously  drawn  to 
define  the  site  of  the  lower  extremity  of  the  symphysis.  When  the 
clitoris  is  attached  high  up  Faraboeuf  advises  a  lambda  (a)  incision, 
the  open  triangle  below,  the  sides  of  which  should  not  exceed  three 
quarters  of  an  inch,  enabling  the  operator  to  avoid  contact  with  that 
organ.  When  the  decussating  fibers  of  the  fascia  are  reached,  the  di- 
vided tissues  should  be  drawn  well  apart  with  retractors,  and  the  linae 


SYMPHYSIOTOMY. 


737 


alba  should  be  neatly  exposed,  at  first  above  and  then  below,  by  strokes 
with  the  bistoury.  In  this  way  the  parellel  ridges  which  furnish  the 
attachments  to  the  adductor  muscles,  and  which  are  covered  by  the  two 
long  longitudinal  bands,  are  brought  into  view,  and  the  intervening 
fossa,  the  sulcus  between  the  spines,  and  the  site  of  the  pubic  arch  may 
be  felt  by  the  examining  fingers. 

When  the  sulcus   between   the   spines   is   not   easily  determined, 
Xeugebauer  advises  the  alternate  extension  and  flexion  of  a  limb  to  aid 


Fig.  ^49.— Division  of  the  snsppnsory  ligament.  The  clitoris  is  drawn  downward,  and  the  lipa- 
ment  is  put  upon  the  stretch  by  the  forked  extremity  of  the  grooved  guard.  The  ligament 
is  then  seized  by  the  forceps  and  cut  across  by  a  knife. 


in  its  localization.  Farabceuf  counsels  making  traction  upon  the  cli- 
toris, and  then  carefully  palpating  the  anterior  symphyseal  fossa  be- 
neath the  suspensory  ligament  to  determine  the  gap  below  the  pubic 
arch. 

The  clitoris  should  next  be  detached  from  the  symphysis,  and  its 
vessel  placed  beyond  the  roach  of  accidental  injury.     To  accomplish 
47 


738 


APPENDIX. 


this,  traction  should  be  made  upon  the  extremity  of  the  clitoris  with 
the  thumb  and  index  finger  to  bring  into  relief  the  filaments  of  the  sus- 
pensory ligament,  which  should  next  be  seized  by  forceps,  and  should  be 
cut  across,  above  the  forceps,  by  a  bistoury.  The  section  should  be  deep 
and  should  extend  the  width  of  the  fossa  to  the  lateral  ridges.  The 
weight  of  the  forceps  frequently  suffices  to  cause  the  descent  of  the 
filaments  attached  to  the  clitoris  and  of  the  clitoris  itself.  The  serous 
opening  beneath  the  symphysis  is  then  exposed  to  view,  or,  when  the 
arch  is  not  perfectly -smooth  and  glistening,  a  blunt  object,  like  the 


Fig.  250.— The  divided  suspensory  ligament  is  drawn  downward  to  expose  the  passage  beneath 

the  arch. 


handle  of  a  scalpel  or  the  rounded  extremity  of  the  grooved  guard  used 
later  for  the  protection  of  the  posterior  symphyseal  vessels,  may  be  em- 
ployed to  scrape  the  surface  from  above  downward  to  the  crura  of  the 
clitoris. 

After  the  arch  has  been  brought  into  view  the  retractor  should  be 
shifted  to  the  upper  portion  of  the  divided  tissues.  The  covering 
fascia  should  be  incised  with  the  cutting  surface  of  a  scalpel  for  a  half 
inch  from  above  downward,  beginning  at  the  line  previously  traced  to 
indicate  the  upper  boundary  of  the  spines.  The  button-hole  opening 
thus  formed  should  be  extended  upward  for  an  inch  and  a  half  with  a 


SYMPHYSIOTOMY. 


739 


pair  of  scissors,  the  blunt-pointed  blade  of  which  should  be  passed 
beneath  the  linea  alba.  The  recti  muscles  are  thus  exposed,  between 
which  the  surgically  clean  extremity  of  the  left  index  finger  should  be 
inserted. 

If  the  adminiculum  obstructs  the  way,  it  should  be  broken  through. 
Under  the  guidance  of  the  finger  the  extremity  of  the  grooved  guard 
should  be  employed  to  separate  the  layer  of  fat  and  connective  tissue 
containing  the  vessels  which  need  to  be  protected  from  injury.  The 
line  of  denudation  should  follow  the  ridge  which  marks  the  articu- 
lation behind,  and  should  extend   downward  until  the  pubic  arch  is 


Fig.  251.— Preliminary  incision  of  the  outer 
covering:  between  the  recti  with  the 
cutting  surface  of  the  scalpel. 


Fig.  252. — Extension  of  the  openin?  made 
by  the  scalpel  by  means  of  scissors. 


reached.  The  grooved  guard  should  then  be  withdrawn,  and,  with  its 
direction  reversed,  should  be  passed  beneath  the  arch  behind  the  pubis 
from  below  upward,  still  under  the  direction  of  the  finger.  When  the 
upper  border  of  the  pubis  is  reached  the  fingers  should  be  withdrawn 
and  the  guard  should  be  held  in  close  contact  with  the  posterior  ridge. 
If  the  head  of  the  child  interferes  with  the  foregoing  manoeuvre,  it 
should  be  held  above  the  pelvic  brim  by  the  liands  of  an  assistant. 


i40 


APPENDIX. 


For  the  section  of  the  symphysis  Faraboeuf  counsels  a  thin,  short, 
narrow  blade.  He  advises  that  a  deep  incision  from  above  downward 
be  first  made  through  the  outer  fibrous  covering,  and  then  with  the 
knife  held  vertically,  with  the  cutting  surface  to  the  front  and  with 


Fig.  25:3.— Introduction  of  the  flnger  and  of  the  p-oovp<l 
Kuard  by  the  suprapubic  route. 


Fm.  254.— 
Knife  of  Faraboeuf. 


the  point  upon  and  behind  the  syni])hysis,  to  divide  the  periosteum, 
the  fibro-cartilage,  and  the  pubic  arch.  Only  tl)e  extremity  of  the 
blade  should  be  employed.  Care  should  be  taken  to  follow  the  same 
route  from  beginning  to  end,  and,  as  the  periosteum  is  approached,  the 
pubis  should  be  separated  to  a  slight  extent  by  a  moderate  abduction 
of  the  knees. 

When  the  section  is  completed  tlie  abduction  of  the  knees  by  as- 
sistants is  followed  by  a  moderate  degree  of  divulsion  at  the  sacro-iliac 
articulation.  If  bleeding  results,  it  should  be  checked  by  a  tampon  of 
sterilized  gauze.  If  the  symptoms  are  not  urgent  and  the  pains  arc 
adequate,  Morisani  and  his  pupils  in  Italy  and  Zweifel  of  Leipsic  prefer 
leaving  the  expulsion  of  the  child  to  the  natural  forces.  As  a  tempo- 
rarv  support  during  the  continuance  of  labor  Caruso  advises  a  bandage 
of  bichloride  gauze  (.1 :  4,000)  around  the  hips.     It  is  claimed  by  its  ad- 


SYMPHYSIOTOiMY.  74I 

vocates  that  this  plan  is  not  the  source  of  unusual  pain  to  the  mother, 
and  that  the  gradual  expansion  of  the  pelvic  diameters  by  the  spon- 
taneous passage  of  the  child  is  attended  with  the  least  degree  of  risk  to 
the  two  lives  involved. 

Faraboeuf,  on  the  other  hand,  insists  that  forcible  divulsion  should 


Fig.  255. — The  grooved  puard  passed  behind  the  symphysi';.  employed  to  protect  the  vessels 
and  organs  from  the  knife  during  the  incision. 

be  employed  by  the  operator  directly  after  section,  as  engagement  is 
thereby  rendered  easy,  and  needless  compression  of  the  child's  head  is 
avoided.  Pinard  and  Yarnier  report  most  favorably  of  this  practice 
in  the  Hopital  Baudelocque.  The  anatomical  lesion  ensuing,  when 
employed  within  proper  limits,  is  confined  to  the  separation  of  the 
periosteum  from  tlie  ileum  for  one  or  two  inches.  Not  a  single  im- 
portant ligament,  nerve,  or  vessel  will  be  injured.  The  measurements 
of  Faraboeuf  place  the  degree  of  permissible  separation  of  the  pubic 
bones  at  two  and  three  quarters  inches  (seven  centimetres).     "Within 


742 


APPENDIX, 


that  limit,  in  a  given  case,  the  distance  should  be  determined  by  the 
diameters  of  the  child's  head.* 

The  force  applied  to  the  knees  to  accomplish  the  necessary  separa- 
tion of  the  ligaments  at  the  sacro-iliac  joints  should,  in  the  main,  be 
eJfected  by  slow,  continuous  pressure.  This  is  best  accomplished  by 
the  operator,  who  stands  between  the  thighs  of  the  patient,  and  who, 
holding  the  knees  with  the  hands,  forces  them  apart  by  synchronous 
movements.  In  this  way  he  should  strip  oif,  stretch,  and  break 
through  the  resistance  at  the  auricular  surfaces,  fiber  by  fiber.  But 
the  movement  must  be  intelligently  conducted,  otherwise  the  liga- 
ments may  yield  suddenly  and  the  separation  become  excessive;  or  the 
resistance  of  a  sacro-iliac  articulation,  due  in  rare  instances  to  anchy- 
losis, more  commonly  to  varying  thicknesses  of  the  fibrous  connections, 
or  to  a  retro-articular  point  of  bony  contact,  may  lead  to  an  unequal 
degree  of  separation  upon  the  two  sides.  x\s  the  outward  rotation  of 
the  ilia  is  always  attended  by  a  descent  of  the  pubic  extremities,  the 
asymmetry  is  easily  recognized  by  their  differing  levels.  A  very  im- 
portant point  in  Faraboeuf's  instruction  has  been  the  demonstration 
that  it  is  possible,  by  flexion  and  adduction  of  the  thigh,  with  the 
weight  of  the  body  thrown  upon  it,  to  produce  complete  fixation  at  one 
joint,  while  force  is  exerted  upon  the  other.     (  Vide  Fig.  238.) 

When  the  child's  head  is  at  the  pelvic  brim  advantage  may  be  taken 
of  the  increase  of  the  sagittal  diameter  produced  by  the  extension  of 
the  lower  extremities,  and,  during  descent,  of  the  increase  of  the  sacro- 
pubic  diameters  due  to  forced  flexion.  At  the  outlet,  owing  to  the 
lack  of  the  pelvic  planes,  it  is  usually  necessary  to  employ  artificial 
means  to  rotate  the  antero-posterior  diameter  of  the  head  from  the 
transverse  to  the  conjugate  diameter.  If  forceps  or  version  is  resorted 
to,  it  must  be  remembered  that  unlike  ordinary  labor,  owing  to  the 
lack  of  support  in  front,  it  is  the  anterior  vaginal  wall  and  bladder, 
rather  than  the  perineum,  which  are  endangered.  The  ga})ing,  there- 
fore, at  the  pubic  bones  should  be  restrained,  as  far  as  compatible  with 
the  birth  of  the  child,  by  pressure  upon  the  sides  of  the  pelvis  exerted 
by  the  hands  of  assistants,  or,  still  better,  by  the  fixation-forceps  con- 
trived by  Farabceuf. 

When  labor  is  ended  three  sutures  of  strong  silk  should  be  passed 
through  the  entire  thickness  of  the  fibro-tendinous  covering  of  the 
symphysis  to  the  bone,  beginning  outside  the  longitudinal  band  which 

*  Farabceuf  has  invented  an  ingenious  instrument,  termed  by  him  the  *'  men- 
purateur-levier-prehenseur,"  which  is  capable  at  the  same  time  of  measuring  the 
bilateral  diameter  of  the  child's  head  and  of  serving  as  a  lever  to  further  its  descent. 
By  it  the  necessary  degree  of  separation  can  be  estimated  in  advance  with  approxi- 
mate exactitude.  He  has  likewise  devised  a  pelvimeter  by  means  of  which  the 
antero-posterior  diameter  of  the  pelvis  can  be  accurately  measured  in  place  of  being 
^estimated. 


SYMPHYSIOTOMY.  743 

furnishes  on  each  side  the  boundary  to  the  symphyseal  fossa.    In  tying 


Fig.  256.— Symphysiotomy.  The  division  of  the  symphysis  is  accomph'shed  by  (1)  section  be- 
tween the  recti  muscles,  to  sever  as  far  as  possible  the  hard,  creaking  bundles  of  the  fibrous 
covering,  and  to  trace  in  front  a  line  corresponding  to  the  groove  of  the  guard,  which  is 
held  firmly  against  the  ridge  corresponding  to  the  articulation  behind.  (2)  By  means  of  a 
short,  narrow  blade,  with  a  rounded  extremity  the  operator  then  cuts  through  the  symphysis 
from  above  downward,  with  the  cutting  edge  of  the  blade  dii-ected  forward,and  under  the 
protection  of  the  grooved  guard. 


744 


APPENDIX. 


the  sutures  care  should  be  taken  to  bring  the  pubic  bones  into  close 
contact — an  action  admirably  accomplished  by  the  fixation-forceps  of 
Faraboeuf. 

Caruso  *  gives  the  Italian  method  as  follows :  Prepare  and  disinfect 
everything  required  for  the  operation  (matting,  gauze,  sutures,  a  curved 
blunt-pointed  bistoury  with  solid  handle,  forceps,  etc.).  Place  patient 
in  obstetrical  position  at  edge  of  bed  ;  shave  the  pubes  and  labia  ma- 


FiG.  j;57.  — Mode  of  introduction  of  sutures.  These  should  he  of  stronp:  silk,  and  should  be  in- 
serted from  the  outer  borders  of  the  lon^ritudinal  bands,  keeping  close  to  the  bones.  It  is 
best  to  begin  on  the  right  side,  which  presents  the  greatest  difficulty. 

jora ;  disinfect  suprapubic  region,  vulva,  perinaMim,  and  vnlvo-vaginal 
canal;  introduce  silver  female  catheter  into  the  bladder.  Then  try  to 
determine  the  situation,  the  height,  the  width,  and  the  direction  of  the 
articulation.  Feel  the  upper  border  and  the  sulcus  between  the  spines, 
the  lower  border,  the  anterior  and  posterior  fibrous  coatings.  Determine 
the  relief  furnished  by  the  interosseous  fibro-cartilage.  Commence  in- 
cision 1-5  centimetres  above  the  symphysis;  cut  vertically  downward 
through  the  soft  structures,  directing  the  incision  to  the  left  when  in 
tlie  proximity  of  the  clitoris:  seven  to  eight  centimetres  will  suffice. 
Separate  the  recti,  and  nick  the  insertions  if  necessary  to  facilitate  access 
to  the  prevesical  tissues.  Then,  holding  the  palmar  surface  of  the  in- 
dex finger  against  the  inner  surface  of  the  pubis,  push  downward  to  the 

*  Caruso,  Contributo  alia  pratica  della  sinfisiotoinia,  Aniiali  di  Ositctricia  e 
Ginecologia,  No.  4,  April,  1892. 


SYMPHYSIOTOMY. 


Y45 


lower  border  of  the  articulation.  An  assistant  should  hold  the  urethra 
downward  and  to  the  right  with  a  sound,  while  the  operator  cuts  with 
a  blunt-pointed  bistoury  from  above  downward  and  from  before  back- 
ward, until  the  triangular  ligament  is  reached. 

At  this  point,  however,  Caruso  advises  raising  the  handle  of  the 
knife,  and,  while  he  continues  to  cut  downward,  directs  the  blunt  ex- 
tremity to  the  front.  The  separation  is  announced  by  a  peculiar 
creaking  characteristic  sound 

and  by  the  space   (three   to         ^^--^  '  '*"'' 

four  centimetres)  between  tlie 
pubic  bones.  At  this  mo- 
ment the  cavity  produced  by 
the  separation  of  the  pubis 
should  be  tamponed  with  cor- 
rosive-sublimate gauze.  Dur- 
ing the  birth  of  the  child  the 
ilia  should  be  supported  by 
assistants.  Finally,  six  to 
seven  sutures  should  be  passed 
through  the  soft  tissues,  tak- 
ing pains  to  include  the  peri- 
chondrium for  at  least  a  cen- 
timetre from  the  divided  ar- 
ticular surfaces.  Then  dress 
with  sublimated  gauze  and 
with  sterilized  cotton. 

Recently,  Dr.  Edward  A. 
Ayers  has  reported  four  cases 
of  symphysiotomy  in  which 
the  subcutaneous  method  was 
employed.     The  mothers  all 

recovered.  In  one  instance  twins  were  delivered ;  both  survived.  In 
another  instance  a  child  weighing  seven  pounds  was  born,  and  is  still 
living.     Two  of  the  children  were  born  dead. 

Dr.  Ayers's  operation  consists  in  raising  the  clitoris  and  passing  be- 
neath a  narrow  sharp-pointed  scalpel  through  the  mucous  membrane 
from  below  upward  in  the  line  of  the  symphysis,  to  within  a  half  inch 
of  the  upper  pubic  border.  A  straight  blunt-pointed  bistoury  is  then 
substituted,  and  is  employed  to  cut  through  the  tissues  of  the 
joint.  Meantime  the  bladder  and  urethra  should  be  held  to  one  side 
with  a  sound,  and  a  finger  in  the  vagina  should  follow  the  blunt 
point  of  the  bistoury  dui'ing  its  descent  through  the  tissues  of  the 
joint. 

Theoretically,  the  advantage  of  preserving  the  integument  intact 
does  not  seem  to  justify  the  sacrifice  of  the  steps  by  means  of  which 


Fig.  258 —Tying:  the  sutures,  while  the  bones  are 
held  in  place  by  Faraboeuf  s  forceps. 


Y4(5  APPENDIX. 

haemorrhage  is  surely  guarded  against,  and  the  bladder  and  retrosym- 
physeal  space  are  protected. 

Doubtless  the  weak  side  of  symphysiotomy  is  the  imperfection  of  all 
the  methods  thus  far  devised  to  secure  coaptation  of  the  parted  sur- 
faces after  the  operation.  Ordinary  bandages  and  binders  become 
quickly  soiled  and  require  frequent  changes.  Metallic  contrivances  to 
exercise  pressure  on  the  hips  and  plaster-of-Paris  bandages  chafe  the 
skin  and  lead  to  the  formation  of  bed-sores.  To  a  less  extent  the  same 
is  true  of  rubber-plaster  strips  which  encircle  the  pelvis.  For  this  rea- 
son Dr.  Dawbarn  recommends  not  to  surround  the  pelvis  entirely,  but 
to  use  strong  adhesive-plaster  strapping  four  inches  wide,  starting  just 
behind  each  trochanter  and  crossing  over  the  pubis.  If,  then,  the  first 
strap  is  re-enforced  by  two  further  thicknesses  of  plaster,  he  states  that 
a  very  reliable  splint  is  produced.*  The  proposition  to  favor  the  union 
of  the  pubic  bones  by  placing  the  patient  upon  a  cot-bed  with  sloping 
sides  seems  open  to  the  objection  that  in  the  prolonged  dorsal  position 
painful  points  of  pressure  will  of  necessity  be  developed. 

For  these  and  similar  reasons  especial  stress  must  be  placed  upon 
direct  suturing  of  the  symphysis,  either  by  silver  wire  passed  through 
the  bones  by  means  of  drills  adapted  to  the  purpose,  or  by  strong  silk 
sutures  made  to  traverse  the  fibrous  structures  which  overlie  the  carti- 
lage and  anterior  borders  of  the  pubic  bones.  The  latter  plan  is  advo- 
cated by  Farabffiuf,  by  Pinard  and  his  colleagues  at  the  Baudelocque 
Hospital,  and  by  Caruso  in  Italy.  By  the  aid  of  deep  sutures  the  acci- 
dental loosening  of  the  external  belt  is  deprived  of  much  of  its  impor- 
tance. In  all  cases  the  patients  should  lie  with  outstretched  limbs  and 
with  the  feet  turned  inward.  Pinard  commends  highly  a  bed  manufac- 
tured by  Bonamy  and  Sarnoy,  of  Paris,  of  which  the  essential  part  is  a 
frame  with  cross-strips  of  webbing  to  be  placed  beneath  the  patient. 
When  the  bed-pan  is  employed  the  frame  is  raised  by  means  of  pulleys, 
and  lifts  the  body  of  the  patient  from  the  bed  without  subjecting  the 
pelvis  to  any  disturbing  movement. 

A  certain  degree  of  diastasis  following  symphysiotomy  is  by  no 
means  rare.  It  is,  however,  for  the  most  part,  temporary,  ending  after 
weeks  or  even  months  in  solid  union.  A  slight  degree  of  mobility 
does  not  prevent  ordinary  exercise  in  the  erect  position.  An  extensive 
separation  may  be  the  source  of  great  discomfort.  In  one  instance 
which  came  under  my  notice,  where  recovery  ultimately  took  place, 
the  patient's  sufferings  were  for  a  time  extreme,  and  led  her  frequently 
to  beg  me,  when  making  my  hospital  visits,  to  put  an  end  to  her 
existence. 

Prognosis. — In  the  278  cases  of  symphysiotomy  collated  by  Xeuge- 

*  A  Case  of  Syinphysiotomy,  by  Robert  H.  M.  Dawbarn,  The  Am.  Journ.  of  Ob- 
stet.,  March,  189G,  p.  3G2. 


SYMPHYSIOTOMY.  747 

bauer  *  between  the  yegirs  1887  and  1894  there  were  31  deaths— i.  e.  the 
.mortality  was  11  per  cent.  In  the  report  of  Morisani  (at  the  Inter- 
national Medical  Congress  in  Eorne,  1894)  the  same  result  was  obtained. 
Of  260  children  alive  at  the  time  of  operation,  17,  or  19  per  cent,  died 
during  or  a  few  hours  subsequent  to  labor.  In  1894,f  according  to  a 
second  report  by  Neugebauer,  there  occurred,  so  far  as  he  was  able  to 
collect  them,  106  cases,  but  details  were  only  given  in  89.  There  were 
in  the  latter  number  8  maternal  deaths  (9  per  cent),  while  the  infantile 
mortality  was  13,  or  15-3  per  cent.  Harris  reported  from  the  United 
States  and  Canada  74  cases  in  fifteen  years  to  June,  1895  (71  in  the  last 
two  years  and  seven  months)  :  10  mothers  and  18  children  perished. 
The  gross  mortality,  therefore,  both  maternal  and  infantile,  will  be  seen 
to  be  heavy.  Deductions  made  from  these  and  similar  aggregations  are, 
however,  apt  to  be  misleading.  They  make  no  allowance  for  appren- 
tice-work, and  yet  in  every  new  operation  a  certain  number  of  casual- 
ties is  the  sad  price  by  which  experience  is  purchased.  They  do  not 
take  into  account  the  deaths  for  which  the  operation  is  in  nowise  re- 
sponsible— viz.,  those  resulting  from  non-puerperal  diseases  in  childbed, 
from  septic  infection  incurred  during  labor,  from  eclampsia,  from  the 
lowered  vitality  of  the  patient  due  to  long  waiting,  and  from  injuries 
resulting  from  attempts  at  forcible  delivery. 

A  juster  perspective  is  obtainable  from  the  study  of  the  reports  of 
selected  operators  of  large  experience.  Thus  Morisani  in  55  cases  op- 
erated upon  by  him  between  March,  1887,  and  October,  1893,  had  a  loss 
of  but  2  mothers  and  3  infants.  Zweifel  has  had  27  cases  (to  the  end 
of  1894),  with  the  loss  of  two  infants  and  with  no  maternal  deaths. J; 
Caruso  in  response  to  a  personal  letter  wrote  me  that  for  the  year  1894, 
from  January  1st  to  November  28th,  there  had  been  in  Naples  12  sym- 
physiotomies. The  mothers  all  recovered ;  3  infants  died.  Gueniot 
has  had  10  operations ;  the  mothers  recovered,  1  child  died.  Pinard 
has  reported  that  up  to  January  1,  1896,  of  69  symphysiotomies  in  the 
Hopital  Baudelocque  7  mothers  and  8  children  died  ;  2  of  the  mater- 
nal deaths  were  due  to  pneumonia,  and  4  to  infection  incurred  before 
entrance  into  the  hospital.  He  regarded  none  of  the  accidents  and 
complications  as  due  to  the  operation.  Queirel  *  states  that  in  55  cases 
occurring  in  the  practices  of  Pinard  and  Varnier  before  the  employment 
of  symphysiotomy,  in  193  cases  of  pregnancy,  152  children  perished, 
whereas  since  its  employment  41  children  have  been  saved. 

The  evidence  is  therefore  clear  that  in  experienced  hands  and  under 

*  Fremmel's  Jahresbericht  fiir  Geb.  und  Gyniik.,  1893,  art.  by  Neugebauer. 
t  Idem.,  1894. 

X  Vide  Heinricius,  Ein  Fall  von  Symphysiotomie,  Monatschr.  f.  Geb.  und  Gynak., 
April,  1896,  p.  298. 

*  QuEiRKL,  Symphysiotomie  et  le  Forceps  au  Detroit  Sup.,  Ann.  de  Gyn.,  Feb., 
1896. 


i-j^j^  APPEXDIX. 

proper  conditions  the  prognosis  of  symphysiotomy  both  as  regards 
mother  and  child  is  favorable,  and  that  the  operation  is  entitled  to  a 
high  standing  among  the  measures  available  in  the  treatment  of  dif- 
ficult labor.  Its  worst  enemies  are  those  who  preach  its  simplicity,  and 
who  io-nore  the  risks  involved  in  its  emplovment.  It  is  not  in  all  cases 
easy  of  accomplishment.  The  avoidance  of  luymorrhuge  and  lacera- 
tion calls  for  constant  vigilance,  and  the  after-treatment  involves  an 
infinite  amount  of  painstaking. 

Indications. — Symphysiotomy  is  advocated  in  contracted  pelves  as  a 
substitute  for  high  forceps,  for  version,  and  for  premature  labor  to 
diminish  the  infant  mortality  due  to  these  manoeuvres.  It  finds  its 
natural  place  in  moderate  degrees  of  pelvic  deformity.  Below  two  and 
three  quarter  inches  in  the  flattened  and  three  inches  in  the  juxto-minor 
pelves,  owing  to  the  risk  of  lacerations  of  the  vesical  and  utero-vaginal 
tissues  incident  to  the  excessive  separation  of  the  pubic  bones,  it  pos- 
sesses a  questionable  advantage  over  the  Ca??arean  section.  As  an  ad- 
ditional resource  in  obstetric  practice  its  importance  can  not  be  too 
highly  valued.  That  its  revival  makes  all  other  measures,  which  im- 
peril to  a  greater  extent  the  life  of  the  fa^tus,  criminal,  is  an  assumption 
that  seems  hardly  warranted.  An  operation  wiiich  to  date  has  involved 
a  maternal  death-rate  of  11  per  cent,*  which  even  in  skilled  hands  may 
be  attended  by  serious  injuries  to  the  soft  parts,  and  which  is  often 
followed  by  a  tedious  convalescence,  to  my  mind  siiould  not  be  un- 
dertaken without  the  consent  of  the  parties  interested. 

Between  two  and  three  quarter  inches  and  three  inches  (three  to 
three  and  a  quarter  in  juxto-minor  pelves)  I  should  personally  prefer 
symphysiotomy.  It  is  less  dangerous  than  the  CiBsarean  section,  and 
the  alternative  is  usually  craniotomy  and  the  basiotribe.  Above  three 
inches  in  flattened  pelves  the  chances  are  more  favorable  than  is  gen- 
erally thought  to  the  birth  of  the  child  by  the  natural  passages.  Leo- 
pold reports  twenty-one  cases  in  one  year  where  the  pelvis  measured 
from  three  inches  to  three  and  a  half  inches  in  which  spontaneous 
delivery  took  place.  If  accommodation  of  the  head  to  the  pelvis  does 
not  occur  as  a  result  of  uterine  action,  before  deciding  upon  symphysi- 
otomy the  physician,  it  seems  to  me,  should  consider  conscientiously 
his  own  qualifications,  the  character  of  the  assistance  at  his  command, 
and  the  extent  to  which  antisepsis  in  the  given  case  is  practicable. 

*  Of  course,  many  of  the  deaths  were  not  due  directly  to  the  operation.  Com- 
parisons, however,  are  made  with  otlier  measures  where  the  same  exceptions  could 
justly  be  claimed. 


IKDEX. 


ABDOAfEN  : 

appearance  of,  in  pregnancr,  86,  94,  99, 100, 

105,  2T8. 
discoloration  of,  in  pregnancy,  loO. 
fat,  iu  wall  of,  obscui'ing  pregnancy,  102. 
fetal,  enlarged,  obstructing  labor,  554. 
ice  to,  in  post-part um  haemorrhage,  588. 
in  anteversion  and  anteflexion,  278. 
injuries  of,  producing  abortion,  308. 
in  puerperal  state,  249. 
inspection  of,  in  pregnancy,  100. 
pain  in,  during  pregnancy,  87. 
palpation  of,  in  pregnancy,  100. 
pendulous,  in  contracted  pelvis,  4G7,  480. 

in  double  uterus,  278. 
size  of,  in  pregnancy,  94,  111. 
skin  of,  in  pregnancy,  87,  100,  105. 
striae  upon,  in  pregnancy,  87,  100,  105. 
Abdominal  muscles,  action  of,  in  labor,  129. 
Abdominal  plates,  49. 
Abdominal  pregnancy,  42,  327,  335,  3-39. 

varieties  of,  336. 
Abdominal  tumors : 

diagnosis  of,  from  pregnancy,  102,  549. 
Abortion  i^vide  labor,  premature),  307. 
alcohol  in,  323. 
anaemia,  causing,  308,  351. 
ana?stliesia  iu,  322. 
arrest  of  threatened,  318. 
artificial,  359. 

indications  for,  359. 
bougies  to  produce,  351. 
carbolic  acid  in,  323,  324,  325. 
care  of  child  after,  356. 
catheterization  to  produce,  351,  356. 
causes,  immediate,  of,  310. 
anteflexion,  310. 

hyperemia  of  gravid  uterus,  310. 
infectious  diseases,  260  et  seq.,  ZO^. 
uterine  contractions,  trom  nervous  influ- 
ences, 311. 
causes,  predisposing,  of,  113,  308. 
atrophy  of  uterine  mucous  membrane,  309. 

549 


Abortion : 

hypertrophy  of  uterine    mucous  mem- 
brane, 310. 
cellulitis  in,  325. 
chill  in,  825. 
chloroform  in,  322. 
cold  in,  318,  321. 
collapse  in,  323. 
complete,  319  et  seq. 
cord,  care  of,  in,  326. 
corpulence  causing,  308, 
Crede's  method  in,  324. 
curette  in,  317,  320,  324,  326, 
death  of  loetus  cau.-ing,  S08. 
definition  of,  307. 
diagnosis  of,  314. 
disposition  to,  308. 

douche  in,  320,  322,  323,  324,  325,  326,  356. 
emesis  causing,  118,  351,  359. 
ergot,  use  of,  in,  320,  321,  323,  461. 
ether,  use  of,  in,  822. 
exercise,  violent,  causing,  113. 
expulsion  of  placenta  iu,  324. 
famine  causing,  308. 
hiemorrhage  in,  309,  311,  312,  313,  319,  325. 

326,  339. 
in  anfemia,  115. 
in  cancer  of  cervix,  310,  547, 
in  cardiac  diseases,  268,  351. 
in  cholera,  264. 
in  chorea,  275,  351. 
incomplete,  results  of,  312,  319,  320. 
in  contracted  pelvis,  494,  497,  498,  500. 
in  decidual  diseases,  308. 
indications  for,  349,  494,  497,  500. 
diseases  which   imperil    life   of  motlicr. 

351. 
habitual  death  of  foetus,  3.50. 
moderate  pelvic  contraction,  849,  359,  494 
497. 
in  double  uterus,  278. 
induction  of,  349. 
in  eclampsia,  578,  581, 


750 


INDEX. 


Abortion : 
in  emesis  of  pre;xnancy,  119  et  seq. 
in  emphysema,  270. 
in  empyema,  270. 
in  endometritis,  285,  286,  287. 
in  heart  diseases,  268. 
in  hydatidiform  mole,  301. 
in  hydramnion,  124,  292. 
in  icterus,  266. 
in  malarial  fever,  264. 
in  measles,  261. 
in  multiple  prejjnancy,  124. 
in  nephritis,  273. 
in  ovarian  tumors,  549. 
in  pernicious  anaemia,  115. 
in  phthisis,  270. 
in  placenta  praevia,  597,  600. 
in  placentitis,  289,  304. 
in  pneumonia,  269,  359. 
in  prolapse  of  uterus,  282. 
in  relapsing  fever,  264. 
in  retention  of  dead  foetus,  307. 
in  retroflexion,  279,  280,  310,  316. 
in  rubeola,  261. 
in  surgical  operations,  270. 
in  syphilis,  272,  350. 
in  typhoid  fever,  264. 
in  typhus  fever,  264. 
in  uterine  hernia,  283. 
in  uterine  tumors,  542,  544,  547. 
in  variola,  261. 
in  vomiting,  119,  351,  359. 
lochia  in,  320,  325. 

membranes,  retention  of,  in,  312,  325. 
methods  for  producing,  351,  360. 
mole,  due  to,  312. 
mortality  from,  315. 
neglected,  treatment  of,  325. 
operations  for  induction  of,  351,  360. 

catheterization  of  uterus,  351. 

choice  of,  356. 

death  from,  355. 

douche,  vaginal,  354. 

galvanization,  355. 

injections  between  uterus  and  ovum,  352. 

mechanical  dilatation  of  cervix,  353,  360. 

rupture  of  membranes,  353. 

tampon,  vaginal,  355. 
opiates  in,  315,  323. 
ovum-forceps,  us?  of,  in,  324. 
pain  in,  311. 

pelvic  cellulitis,  complicating,  325. 
peritonitis,  coinplieating,  313,  325,  355. 
placental  detachment  in,  325. 
polypi,  fibrous,  removal  of,  after,  313,  326. 
prognosis  in,  315. 
prophylaxis  of,  316. 
recurrent,  317. 
retention  of  membranes  in,  312,  313,  325. 


Abortion : 

rupture  of  uterus  in,  353. 

septicaemia,  complicating,  313,  325. 

shock,  in  artificial,  353. 

sponge-tents  in,  324,  353,  360. 

stimulants  in,  323. 

subinvolution  after,  314. 

symptoms  of,  311,  319. 

tampon,  vaginal,  use  of,  in,  320,  322,  323, 
324,  326. 

tents  in,  324,  353,  360. 

threatened,  arrest  of,  318. 

time  for,  349,  360. 

treatment  of,  316. 
of  threatened,  318. 
prophylactic,  316. 
when  inevitable,  319. 
when  neglected,  S25. 

tubal,  339. 

version  in,  356. 

viburnum  prunilbliura  in,  317,  318. 

violence  causing,  308. 

with  monsters,  557. 
Abscesses : 

in  mastitis,  709. 

in  phlegmasia  alba  dolens,  705. 

in  puerperal  lever,  600,  661,  674,  677,  680, 
700. 

pelvic,  aspiration  in,  700. 

psoas,  in  puerperal  fever,  077. 
Acardia,  in  multiple  pregnancy,  229. 
Acardiacus,  557. 
Accidental  haemorrhage,  594,  597,  606. 

treatment  of,  607. 
Accouchement  ^f or ce^  in  placenta  prsevia,  602, 

652. 
Accoucheur^  armamentarium  of,  206. 
Accphalus,  558. 
Acid,  muriatic,  in  nausea,  117. 
Aconite,  in  face-ache,  122. 
Acormus,  559. 
Adipocere,  304,  306. 
^Eqitahiliter  justo-ininor  pelvis,  465,  471, 485, 

495,  512. 
After-coming  head : 

forceps  to,  399. 

in  contracted  pelvis,  487. 

perforation  of,  418. 
After-pains,  224,  244,  252,  672. 
Air,  collapse  and  death  from  entry  of,  into 
uterine  vessels,  355,  647. 

fresh,  in  pregnancy,  112. 
Air-passages,  catheterization  of,  in  asphyxia 
neonatorum^  644. 

development  ot,  48,  64. 
Albumen,  of  blood,  in  pregnancy,  89,  115. 
Albuminuria: 

in  eclampsia,  567,  569  et  seq. 

in  hydrnmnion,  292. 


INDEX. 


751 


Albuminuria: 

in  pregnancy,  91, 118,  2G2,  268,  273,  275,  307. 

in  septicaemia,  680. 

treatment  of,  577. 
Alcohol,  use  of,  in  abortion,  323. 

in  puerperal  fever,  697. 
Alimentation,  rectal : 

in  anaemia,  114. 

in  emesis,  119. 
Alkalies,  in  albuminuria,  577. 
Allantois,  51,  52,  61,  63. 
Amaurosis,  in  eclampsia,  567. 

in  pregnancy,  91. 
Amblyopia,  in  eclampsia,  567,  569. 

in  pregnancy,  91. 
Amenorrhcea  of  pregnancy,  92,  93. 
Ammonia,  intravenous  injection  of,  in  cere- 
bral anaemia,  590. 

in  heart-burn,  121. 

in  pneumonia,  270. 

in  pulmonary  embolism,  650. 
Amnion,  47,  50,  60,  61,  63,  64,  123. 

anomalies  of,  290. 
causing  inertia  uteri^  455. 

dropsy  of,  75,  95,  103,  124,  290,  561. 

fluid  of,  61. 
Amniotic  fluid,  61. 

anomalies  of,  290. 

composition  of,  61. 

deficiency  of,  293. 

escape  of,  132,  312,  320. 

obscuring  pregnancy,  95. 
AmorpTiug^  558. 

Ampulla,  of  Fallopian  tube,  19. 
Amputation,  spontaneous  intra-uterine,  296. 
Anaemia: 

alimentation,  rectal,  in,  114. 

causing  abortion,  308. 

causing  insanity,  703. 

cerebral,  causing  eclampsia,  574,  575. 

ether,  use  of,  in,  590. 

hypodermic  injection  of  ammonia  in,  590. 

transfusion  in,  590. 

treatment  of,  589. 

in  abortion,  323. 

indicating  abortion,  351. 

in  extra-uterine  pregnancy,  338. 

in  labor  and  childbed,  645. 

va.  placenta  jircBvia,  598. 

in  post-pai'tum  haemorrhage,  589. 

in  pregnancy,  114,  122. 

in  thrombus  of  vagina  and  vulva,  625. 

pernicious,  in  pregnancy,  114. 
treatment  of,  114. 
Anaesthetics : 

in  abortion,  322. 

in  breech  and  foot  presentations,  383,  387. 

in  brow  presentations,  190. 

in  Caesarean  section,  439. 


Anaesthetics : 

in  craniotomy,  414. 

in  diagnosis  of  pregnancy,  102,  341. 

in  eclampsia,  579. 

in  forceps  deliveries,  367. 

in  inverslo  uteri,  608. 

in  irregular  pains  of  first  sta^e  of  labor,  457. 

in  midwifery,  225. 

in  normal  labor,  210,  225,  268. 

in  painful  labor,  463,  502. 

in  precipitate  labor,  453. 

in  Thomas's  operation,  449. 

in  version,  404,  406,  410. 

post-partum,  623. 
Ancesthesia,  in  pregnancy,  91,  102,  281. 

in  retroflexion,  281. 
Anasarca,  fetal,  causing  dystocia,  555. 
Anchylosis  of  fetal  jomts,  causing  dystocia, 

556. 
Anencephalus,  559. 
Anodynes : 

in  eclampsia,  579. 

in  emesis  of  pregnancy,  117.  119. 

in  lacerations  of  pcrinaeum,  624. 

in  mania,  703. 

in  neuralgia,  122. 

in  painful  first  stage,  4G3. 

in  post-partum,  ha'niorrliage,  585. 

in  precipitate  labor,  453. 

in  protracted  fljst  stage,  456. 

in  puerperal  fever,  464,  695. 

in  puerperal  state,  252,  705. 

in  shock,  650. 

in  vaginal  thrombus,  628. 
Anorexia,  in  pregnancy,  114. 

post-partum,  248. 
Anteflexion,  in  pregnancy,  116,  278,  310. 

in  the  puerperal  state,  244,  249,  592. 
Anteversion  in  pregnancy,  80,  278. 

normal,  16. 
Antipyretic  treatment  of  puerperal  fever,  696, 
697. 

by  quinia,  696. 

by  salicylate  of  soda,  696. 

in  scarlatina,  263. 
Antipyrine,  in  puerperal  fever,  697. 
Antiseptic  treatment,  of  puerperal  patients, 

253,  687  et  seq. 
Antiseptics  in  Caesarean  section,  439,  441. 
Anus: 

development  of,  63. 

imperforate,  256,  296. 

laceration  of  sphincter  of,  623. 
Aorta,  compression  of,  in  post  partvm  haem- 
orrhage, 24,  588. 
Apnoea  of  fojtus,  635,  636,  638. 
Apoplexy,  utero-placental,  288. 
Appetite  in  pregnancy,  114. 

after  delivery,  240. 


[52 


INDEX. 


Apron,  Hottentot,  4. 
Arbor  iiitce  iiterina^  13,  31. 

development  of,  31. 
Area,  germinativa,  47,  50. 

embryonic,  47,  48,  62. 
Areola,  mwrnmce,  88,  90,  94,  99. 

follicles,  sebaceous,  of,  88. 

in  the  puerperal  state,  249. 

of  preguancy,  88,  90,  94,  99,  249. 

secondary,  of  Montgomery,  88,  94,  99. 
Armamentariura  of  accoucheur,  206. 

for  breech  presentations,  384,  388. 

for  Csesarean  section,  439. 

for  lacerations,  624. 

for  post'partum  hsemorrhage,  585. 
Arms : 

liberation  of,  in  breech  presentations,  394. 
when  extended,  394. 
when  flexed,  394. 

release  of  anterior,  394. 

release  of  posterior,  394. 

setting  of  fractured,  395. 
Arteria  aortica,  24. 
Arteria  uterina,  hyporjas'.rica,  23. 

in  pregnancy,  98. 

uterine  bruit  in,  96,  9a,  100,  103. 
Arteries : 

aorta,  68. 

internal  spermatic,  25. 

ovarian,  25. 

pulmonary,  68. 

thrill  in,  in  pregnancy,  100. 

umbilical,  53,  60,  66,  250. 

uterine,  23,  24,  59,  77,  79,  103. 

vaginal,  10. 
Articulations : 

anchylosis  of  fetal,  obstructing  labor,  556. 

of  fetal  head  with  spinal  column,  171. 

pelvic,  145,  275. 

pelvic,  mobility  of,  in  labor,  148,  275. 

rupture  of,  628. 

sacro-iliac,  145. 
Artificial  feeding  of  infants,  257. 
Artificial  respiration,   in    asphyxia   neonato- 
rum, 643. 

Schultze's  method  of,  643. 

Sylvester's  method  of,  644. 
Ascites,  fetal,  obstructing  labor,  554. 

indicating  abortion,  351. 

in  ovarian  tumors,  549. 

mistaken  for  pregnancy,  102. 

obscuring  pregnancy,  102,  268,  292. 
Aseptic  dressing,  after  labor,  225. 
Asphyxia  livida,  639. 

pallida,  639. 
Asphyxia  neonatorum,  215,  368,  4G0,  617,  635. 

definition  of,  635. 

di.ignOsis  of,  641. 

etiology  of,  635. 


Asphyxia  neonatorum  : 

in  first  stage,  640. 

in  second  stage,  460,  640, 

morbid  anatomy  of,  639. 

prognosis  of,  642. 

respiration,  artificial,  in,  643. 

treatment  of,  642. 
Aspiration  of  pelvic  abscess,  700. 

of  air-passages,  644. 
Asthenia,  in  pregnancy,  114. 
Astringents : 

in  post-part um  hemorrhage,  587,  622. 

in  puerperal  haemorrhage,  592. 

in  vaginal  thrombus,  628. 
Atelectasis  after  asphyxia,  643. 
Atmosphere,  poisons   in,   causing   puerperal 

fever,  681. 
Atony,  uterine,  in  third  stage  of  labor,  461, 
584. 

causing  spontaneous  version,  562. 

forceps  in,  375. 

in  double  uterus,  278. 
Atresia  of  genital  canal,  535. 

symptoms  of,  541. 

treatment  of,  541. 
Atresia,  uterine,  539. 

from  cervical  thrombus,  540. 

from  cicatrices,  540. 

from  congluiinatio  orificii  externi,  539. 

from  elongation  of  anterior  lip,  540. 

from  ovarian  tumors,  548. 

from  rigidity  of  os,  .540. 

from  tumors,  541,  542,  547. 

treatment  of,  541. 
Atresia,  vaginal,  536. 

accidental,  536. 

congenital,  536. 

from  cystic  degeneration  of  vaginal  walls, 
538. 

from  cystocele,  537. 

from  ccchinococci,  538. 

from  neoplasmata,  538. 

from  prolapse,  537. 

from  rectocelc,  537. 

from  retention  of  urine,  537. 

from  thrombus,  588,  625. 

from  tumors,  588. 

from  vaginal  hernia,  537. 

from  vaginismus,  538. 

from  vesical  calculi,  537. 

treatment  of,  541. 
Atresia,  vulvar,  535. 

Atrophy,  of  uterine  mucous  membrane,  caus- 
ing abortion,  309. 
Atropia,  use  of,  in  protracted  first  and  second 
stages  of  labor,  457,  462,  650. 

injection  of,  in  extra-uterine  pregnancy. S45 

in  salivation,  121. 

It  shock,  650, 


INDEX. 


T53 


attitude  of  foetus,  72  et  seq. 
a^uscultation,  as  aid  to  diagnosu^  of  prcg 
nancy,  96,  10-2, 106. 

Axis: 

of  inferior  pelvic  strait,  lo-i. 
of  superior  pelvic  strait,  152. 


Bacilli  in  puerperal  fever,  666. 
Bacteria: 

action  of,  on  blood,  ':68. 

in  normal  lochia,  245,  684. 

i.,  puerperal  fever,  606  .^.e^.,  081,  689. 

Bagd^vaters,132,139,209,4b3. 
in  breech  cases,  198. 

nmture  of  in  abortion,  320,  3o3. 

ruptuieoi  182,342,600. 

Eallottfiment,  96,  101,  1^4,  lo^,        , 

in  hydatidiforra  mole,  301. 
Bandage,  application  of  abdominal,  224,  25o. 
Bandl   rins?  of,  84,  137,  611.  , 

^ews  otrregavding  changes  in  gravid  uter- 

us,  84. 
Barnes's  dilator: 

in  accidental  luemorrbage,  C07. 

in  breech  presentations,  204. 

in  craniotomy,  414. 

in  ecliimpj^ia,  580. 

in  hvdatidiform  mole,  302. 

in  iiilernal  hieinorrhage,  607. 

in  laparo-elytrotomy,  448. 

in  placenta  prsevia,  602  et  seq. 

in  prolapsed  funis,  631. 

in  protracted  first  stage  of  labor,  45.,  458 

in  vaginal  thrombus,  627. 

to  induce  premature  delivery,  3o3,  3o6. 
Bartholin,  glands  of,  6. 
Basylist,  Simpson's,  416. 

"cold,  in  puerperal  fever,  698. 

in  scarlatina,  263. 
hot,  in  eclampsia,  578,  580. 
in  painful  labor,  463. 
of  ncw-bora  infant,  256. 
warm,  in  tardy  labor,  457. 
Battledoor  placenta,  298. 
Bed,  preparation  of,  for  labor,  20b. 
Bedstead,  obstetrical,  206        _     ,    „^,    0.5 
Binder,  application  of  abdominal,  224   -o5. 

in  relaxation  of  pelvic  symphyses,  276. 
Bismuth,  subnitrate,  in  nausea  of  pregnancj 

117. 
Bladder:  _  ^ 

calculus  in,  obstructing  labor,  537. 

distention  of  fetal,  <^^^'^'^- 
distention  of,  retarding  labor,  4ob,  084. 

in  pregnancy,  88. 
Blastodermic  vesicle,  47,  50. 
epiblast  of,  47,  48,  50. 
hypoblast  of,  47,  48,  50. 
mesoblastof,47,48,49,50. 

48 


Blastophore,  46.         _ 
Bleeding,  in  eclampsia,  579,  581. 

Blood:  ca  n^ 

changes  of,  in  pregnancy,  88,  11  rf. 

defibrinated,  in  emesis,  118. 
development  of  corpuscles  ot,  4». 
Jninsfusion  of,  in  post-partu.^  hemorrhage. 

590. 
vessels,  development  of,  48. 
Blunt  hook : 
iu  breech  cases,  388,  393. 
Taylor's,  430. 
use  of,  in  craniotomy,  429. 
Bodies,  Wolfaan,  29. 
Bones,  development  of,  48,  64. 

pressure  of  pelvis  on,  490. 
Borax,  in  pruritus,  123. 
Bottle  for  artificial  feeding  of  inlants,  259. 

care  of,  259. 
l^-n'protracted  first  stage  of  labor,  457. 

to  produce  abortion,  351,  356. 
Bowel,  paralysis  of,  in  puerpeval  fever,  678. 

Brain,  development  ot,  48,  64. 

Brtndy,  ^n post-p.rtura  hemorrhage,  590. 

Breasts : 
anatomy  of,  246. 
areola  of :  „,> 

in  pregnancy,  88,  90,  94,  99. 
in  puerperal  state,  249. 
secondary,  88,  99. 
care  of,  in  puerperal  state,  255. 
changes  in,  during  pregnancy,  87,  S8,  9U, 
94,  99,  105,  106. 
during  puerperal  state,  249. 
diseases  of,  701,  706. 
abscesses  of,  709,  711. 
causes  of  mastitis,  709. 
defective  milk,  706. 
erythema,  707. 
galactocele,  712. 
galaetorrhosa,  706. 
inflammation  of,  709- 
mastitis,  parenchymatous,  709. 

treatment  of,  710. 
nipples,  fissured,  707. 
nipples,  sore,  706. 
treatment  of,  707. 

erectility  of,  83. 

in  case  offetal  death,  106. 

in  new-born  child,  2.50. 
in  puerperal  state,  249,  254,  255. 
of  good  wet-nurse,  256. 
pain  in,  during  pregnancy,  8.,  94,  99. 
symptoms  of,  relatin-  to  pregnancy,  87,  88, 
90,94,99,105,106. 

veins  of.  in  pregnancy,  87,  94,  99. 
veins  01,  lu  I  382-390  (wrf« 

Breech  presentations,  169,  197,  ^e^  oav  v 
presentations,  breech). 


754 


INDEX. 


Breech  presentations : 

arms,  liberation  ot,  in,  394. 

asphyxia  in,  639. 

causes  of,  197. 

configuration  of  foetus  in,  202. 

cord,  management  of,  in,  204,  393. 

diagnosis  of,  191,  198. 

exceptional  cases  of,  395. 

extraction  in,  382  et  stq. 

forceps  in,  388,  399,  639. 

frequency  of,  197. 

head  in,  200,  396,  399. 

heart-sounds  in,  103. 

in  contracted  pelvis,  487. 

in  hydrocephalus,  552,  553. 

irregularities  in  mechanism  of,  201. 

mechanism  of,  199. 

membranes,  bag  of,  in,  193. 

prognosis  in,  203. 

l)rolapse  of  cord  in,  629. 

rotation  in,  199,  395. 

shoulders  in,  199. 

traction,  direction  of,  in,  385. 

treatment  of,  204. 
Bregma,  70,  166. 

Bright's  disease,  causins:  eclampsia,  571. 
Brim  of  pelvis,  151,  154,  157,  169,  465  {vide 
strait,  superior). 

ai>plicatiou  of  torceps  at,  375. 

circumference  of,  152. 

diameters  of,  151,  154,  157,  169. 

extraction  with  head  at,  393. 

Tarnier's  forceps  at,  377. 

Taylor's  forceps  at,  377. 
Broad  ligaments,  14. 
Bromides,  use  of: 

in  chorea,  275. 

in  eclampsia,  578,  580. 

in  emesis  of  pregnancy,  118,  119. 

in  insomnia,  122. 

in  nausea,  117,  119. 

in  puerperal  insanity,  703. 
Brow  presentations,  169,  194,  481,  487. 

configuration  of  head  in,  194. 

diagnosis  of,  194. 

meclianLsm  of,  194. 

prognosis  in,  195. 

treatment  of,  196. 
Bniit^  uterine,  in  pregn.ancy,  96,  98, 100, 103. 

effect  of  pains  on,  97. 

placental,  24,  98. 
Brunettes,  areola  of,  88. 
Bulhi  vestihuU  vagina;,  4,  162. 

erectility  of,  5. 

laceration  of,  622. 

pars  intermedia  of,  5. 

Cesarean  section,  436. 
abdominal  wound,  closure  of,  after,  441. 


Csesarean  section : 

after-treatment  of,  441. 

anaesthesia  in,  439. 

armamentarium  for,  439. 

assistant's  duties  in,  439. 

checking  haemorrhage  in,  440,  441,  444,  446. 

closure  of  wound  after,  441. 

definition  of,  436. 

disinfection  in,  439  et  seq. 

dressing  of  wound  after,  439,  441. 

ergot  in,  441. 

extraction  of  foetus  after,  440. 

hicmorrhage  in,  treatment  of,  440,  444,  446. 

history  of,  436. 

incision  in  the  abdominal  wall  during,  440. 

incision  into  uterus  during,  440. 

indications  for,  438,  494,  497,  499,  513,  518, 
521,  524,  528,  533,  618,  651. 

in  real  or  apparent  death  of  the  mother, 
651. 

instead  of  abortion,  359. 

instruments  neces.-^ary  for,  439. 

in  uterine  tumors,  545,  548. 

membranes,  rupture  of,  in,  440. 

operation  of,  439. 
stages  in,  440. 

Porro's  operation  in,  442. 

preparations  for,  439,  440. 

prognosis  of,  436  et  seq.,  443,  444. 
causes  for  bad,  443. 
in  lying-in  hospitals,  437,  439. 

removal  of  placenta  in,  440. 

statistics  of,  in  United  States,  437. 

stump,  treatment  of,  in,  446. 

sutures  in,  441. 

Thomas's  operation  in,  447. 

time  for,  439. 

treatment,  after-,  of,  441. 
Calcareous  degeneration : 

of  cord,  298. 

of  foetus,  306,  327.  337,  340. 
Calculi  : 

impacted,  mistaken  for  exostoses,  537. 

vesical,  obstructing  labor,  537. 
Calomel : 

in  Cesarean  section,  441. 

in  metritis,  464. 

in  perimetritis,  464,  696. 
Camplior,  in  insomnia,  122. 

in  pniritus,  1 22. 
Canal,  cervical,  13,  83,  106. 
Canal,  genital: 

atresia  of,  535. 

ruptures  of,  610. 
Cancer,  uterine,  310,  438,  546. 

vulvar,  536. 
Capvt  svccedanenm  : 

in  brow  presentations,  194. 

in  contracted  pelvis,  483,  489. 


INDEX. 


755 


Caput  succedaneum  : 

indicating  iorceps-delivery,  3fi9. 

in  face  presentations,  190. 

in  forceps-deliveries,  369. 

in  puerperal  state,  250. 

in  vertex  presentations,  181. 
Carbolic  acid : 

m  abortion,  320,  322-325,  354,  356. 

in  Cuesarian  section,  440. 

in  care  of  cord,  256. 

in  erosions  of  cervix,  120. 

in  mastitis,  711. 

in  perineal  rupture,  623. 

in  pruritus,  122. 

in  puerperal  state,  224,  253,  693. 

in  Thomas's  operation,  451. 

in  uterine  rupture.,  619. 
Carbonic-acid  water  in  nausea  of  pregnancy, 

117. 
Carbonic  oxide,  increase  of,  in  blood  during 

prcy:nancy,  89. 
Cardiac    diseases,    complicating    pregnancy, 
266,  351,359. 

causing  abortion,  266,  351,  359. 
Carunculoi  inyrtiformes : 

formation  of,  7,  105. 
Casts,  in  eclampsia,  567,  569  et  seq. 
Cathartics : 

in  eclampsia,  578,  580. 

in  pregnancy,  115. 

in  puerperal  state,  254. 
Catheter : 

in  asphyxia,  644. 

in  reposition  of  cord,  412,  634. 

post-partum^  252. 
Cattieterization : 

in  labor,  normal,  208. 

in  post-partum  hemorrhage,  586. 

in  retention,  537. 

in  retroflexion,  281. 

of  air-passages,   in,  aspJii/xict  neonaiorum, 
644. 

uterine,  to  produce  premature  delivery,  351, 
580. 
Cat's  chorion  :  villi  of,  56. 
Caul,  133. 
Cellulitis : 

in  abortion,  325. 

in  puerperal  i'ever,  658. 
Center,  motor,  for  uterine  contractions,  126. 
Cephalic  version,  401. 
Cephalalgia,  in  pregnancy,  122. 

in  puerperal  state,  248. 
Cephalotomy,  431. 
Cephalotribe,  420. 

action  of,  422,  423. 

application  of,  425. 

B.iudclocque's,  420. 

C!ot's,  421. 


Cephalotribe : 

dangers  of,  424. 

in  breech  cases,  388,  393. 

in  obstructed  labor,  555. 

Lusk's,  422. 

objections  to,  423. 

Scanzoni's,  421. 
Cephalotripsy,  425. 
Cerebellum,  development  of,  48,  64. 
Cerebral  vesicles,  63. 
Cerebrum,  development  of,  50,  63. 
Cerium,   oxalate,   in    nausea  of   pregnancy, 

117. 
Cervix  uteri,  12,  26. 

anatomy  of,  13,  26. 

apparent  shortening  of,  in  pregnancy,  81. 
explanation  of,  83. 

arbor  mtoi  of,  13. 

atresia  of,  539. 

canal  of,  13,  83,  106. 

cancer  of,  310,  438,  546. 

changes  of,  in  pregnancy,  79,  80,  81-86,  95, 
105,  116,  138,  282. 

connective  tissue  of,  17. 

cysts  of,  542. 

dilatation  of,  in  labor,  131,  137,  13^,  199, 
302,  455,  483,  540. 
mechanism  of,  131. 

dilatation  of,  in  emesis  of  pregnancy,  119 
et  feq. 
to  induce  abortion,  353,  360. 

double,  277. 

erectility  of,  26. 

erosion  of,  in  pregnancy,  81,  116,  120. 

examination  of,  in  pregnancy,  104,  105. 

ganglion  of,  27,  77,  126. 

glands  of,  19,  81. 

hyperemia  of,  in  pregnancy,  138. 

liypertrophy  of,  282. 

in  placenta  prsevia,  600. 

in  puerperal  state,  243,  249. 

laceration  of,  105,  203,  539,  540,  620. 

lip,  anterior,  obliteration  of,  in  pregnancy, 
83,  105. 

mechanical  dilatation  of,  to  produce  abor- 
tion, 353,  360. 

mucous  membrane  of,  19,  81,  95. 

myoma  of,  542. 

non  shortening  of,  in  pregnancy,  81-83,  85. 

peculiarities,  anatomical,  of,  26. 

portio  vaginalis  of,  12. 
lacerations  of,  620. 

position  of,  in  pregnancy,  82-85,  104. 

stricture  of,  539. 

thrombus  of,  540. 

tumors  of,  542. 

ulcers  of,  in  puerperal  fever,  656. 

veins  of,  26. 

walls  of,  17. 


756 


INDEX. 


Child  {vide  foetus) : 

asphyxia  of,  215,  368,  635. 

-bed,  disease  of,  653. 
insanity  of,  701. 
physiology  and  manageinciit  of,  238. 

breasts  of  new-born,  250. 

care  of  premature,  356. 

conditions  iniiuenciuj^  size  of,  69. 

extraction  of,  in  real  or  apparent  death  of 
mother,  C50. 
after  perforation,  419. 

icterus  of  new-born,  250. 

length  of  new-born,  69. 

milk  prepared  for,  257. 

size  of,  69. 

weight  of  new-born,  69. 
Chill,  post-partum^  238,  248. 

in  abortion,  325. 

in  fetal  death,  106. 

in  labor,  134. 

in  phlegmasia,  705. 

in  puerperal  fever,  464,  071  et  seq. 
Chin,  traction  on,  m  breech  cases,  396. 
Chloral : 

in  chorea,  275. 

in  eclampsia,  578  et  seq. 

in  emesis  of  pregnancy,  117,  119. 

in  face-ache,  122. 

in  insomnia  of  pregnancy,  122. 

in  puerperal  insanity,  703. 

in  tardy  labor,  457,  502. 
Chloroform : 

effect  of,  on  pains,  227. 

in  abortion,  322. 

in  chorea,  275. 

in  craniotomy,  414. 

in  diagnosis  of  pregnancy,  102. 

in  eclampsia,  579,  581. 

in  face-ache,  1.2. 

in  labor,  210,  226,  208,  457,  463. 

in  pruritus,  122. 

post-partum,  623. 
Cholera,  causing  abortion,  204. 

complicating  pregnancy,  203. 
Chorda  dorsalis,  49. 

Chorea,   complicating   pregnancy,    114,    274. 
351. 

indicating  abortion,  351. 

treatment  of,  275. 
Chorion: 

abortion  from  disease  of,  308. 

formation  of,  51,  52,  53,  64,  123. 

permanent,  53. 

villi  of,  51,  52,  54,  55,  289,  329. 
in  cat,  56. 

inhydatidifbrm  mole,  298. 
in  mare,  55. 
Cicatrices : 

atresia,  uterine,  from,  540. 


Cicatrices : 

of  OS,  obstructing  labor,  540. 

of   vagina,    obstructing    labor,   536    {vide 
atresia,  vaginal). 
Ciliated  epithelium,  columnar : 

in  Fallopian  tube,  21,  42,  328. 

influence  of,  on  migration  ol  ovum,  42. 

in  glands  of  body,  18. 

in  glands  of  cervix,  19. 

in  peritonaeum  of  batrachians,  42. 
Circle  of  Baudelocque,  467. 
Circulation : 

disorders  of,  in  pregnancy,  114,  115. 

entrance  of  air  into,  647. 

fetal,  66,  68,  250,  637. 

varicose  veins  due  to  disorders  of,  in  preg- 
nancy, 88,  115. 
Cleavage  of  ovum,  46.  , 

Clitoris : 

anatomy  of,  3,  102. 

bulbs,  terminal  of,  3. 

corpus  of,  3. 

crura  of,  3,  162. 

development  of,  33,  64. 

frenulum  of,  4. 

glans  of,  3. 

prreputium  of,  4. 
Cloaca,  48. 

Coccygeus  muscle,  160. 
Coccyx,  anatomy  of,  142. 

mobility  of,  142,  149,  534. 
Codeia,  in  emesis  of  pregnancy,  119. 

in  insomnia,  122. 
Coiling  of  cord,  204,  215,  290. 
Coitus,  in  pregnancy,  113,  116. 
Cold: 

in  abortion,  318,  321. 

in  mastitis,  711. 

in  post-partum  hfcmorrhage,  585,  627. 

in  puei-peral  fever,  697. 

in  puerperal  mania,  703. 
Collapse,  in  labor  and  childbed,  645,  648. 

in  abortion,  323. 

in  extra-uterine  pregnancy,  338. 

in  internal  haemorrhage,  606. 

in  uterine  rupture,  615. 
Colostrum,  248. 
Colpeurynter : 

in  abortion,  355. 

in  placenta  pr.nsvia,  002. 
Colpohyperplasia  eijstica  : 

vaginal  atresia  i'rom,  538. 
Columns,  vaginal,  9. 

Commissures,  anterior  and  posterior,  of  la- 
bia, 3. 
Complications  of  pregnancy,  260. 
Computing  day  of  confinement,  108-111. 
Conception,  40,  42. 

date  of,  106. 


INDEX. 


75^ 


Confinement,  prediction  of  day  of,  lifS-lll. 
Congenital  encephalocele,  553. 
Conglutinatk)  orijicil  externi: 

atresia  from,  5.59. 
Conjugate  diameter  of  pelvis,  151. 

measurement  of  diagonal,  4G9,  470. 

measurement  of  external,  4(!9. 

measurement  of  vera,  469,  470. 
<  'onstipation : 

iu  pregnancy,  88.  90,  116,  118,  122,  339. 

in  retroflexion,  with  incarceration,  250. 

post-partum,  240,  675,  078. 
Oonstridor  vagina',  162,  214. 
Contracted    pelvis,    465    {vide    pelvis,    con- 
tracted). 

Ctesarean  section  in,  438. 

diagnosis  of,  466. 

frequency  of,  466. 

varieties  of,  465. 
Contractions,  uterine,  127,  311.  454,  582. 

center  fur  uterine,  126. 

hour-glass,  of  uterus,  462. 

painless,  130,  131. 

pelvic,  resources  of  treatment  in,  493. 

ring,  137,  138,  462,  611,  014. 
Convulsions,  puerperal,  567  {vide  eclampsia). 

indicating  abortion,  351. 

indicating  forceps,  368,  375. 

in  placenta  pra^via,  599. 
Cord,  umbilical,  00  {vide  ftinis). 

anomalies  of,  293. 

arteries  of,  60,  61,  250. 

calcareous  degeneration  of,  298. 
•care  of,  in  abortion,  326. 

in  infants,  256. 
coiling  of,  204,  215,  296. 
cysts  of,  297. 
degenerations  of,  297. 
expression  of,  630. 
formation  of,  00,  63,  64. 
fully  developed,  61. 
gelatin  of,  61. 
htemorrhage  from,  453. 
hernias  of,  296. 
in  puerperal  state,  250. 
knots  in,  295. 

laceration  of,  in  precipitate  labor,  453. 
length  of,  61. 

ligation,  late,  of,  216  et  seq. 
management  of,   in  breech   presentations, 

393. 
marginal  insertion  of,  298. 
prolapse  of,  510,  561,  629  {vide  funis,  pro- 
lapse of), 
reposition  of,  631. 
shortness  of,  causing  dystocia,  559. 
souffle  in.  98. 

stenosis  of  vessels  of,  297,  303. 
structure  of,  61. 


Cord: 
torsion  of,  293,  303. 
traction  on,  in  labor,  220,  221. 
traction  on,  in  retained  placenta,  463,  593. 
tying  of,  in  labor,  215,  216,  236. 
vein  of,  61,  250. 
vessels  of,  60,  01. 
Cordiform  uterus,  34. 
Corium,  development  of,  48. 
Cornua,  of  uterus,  33. 
Corpulence,  causing  abortion,  308. 
Corpus,  of  uterus,  12. 
Corpus  liiteum: 
anatomy  of,  39,  40. 
false,  41. 
formation  of,  39. 
true,  41. 
Corrosive  sublimate,  use  of,  in  obstetrics,  687, 

688,  690,  692,  694. 
Cortex,  of  ovary,  23. 
Cotton,  absorbent,  after  labor, 
Cotyledon,  placental,  56,  59. 
Cracked  nipple,  708. 
Cramps  in  pregnancy,  88. 
Cranial  presentations,  169  et  seq.  {vide  presen- 
tations, vertex). 
Cranioclast,  425,  617. 
action  of,  425  ct  seq. 
application  of,  428. 
Braun's,  426. 
Simpson's,  425. 
Craniotomy,  413. 
anaesthetics  in,  414. 
basylist  of  Simpson  in,  416. 
before  version,  430. 
Blot's  cephalotribe  in,  421. 
Blot's  perforator  in,  415. 
Braun's  cranioclast  in,  426. 
cephalotribes  in,  421. 
contraindications  for,  499. 
contrasted  with  version,  494. 
craniotomy-forceps  of  Meigs  in,  428. 
crotchet  and  blunt  liook  in,  429. 
dangers  of,  in  contracted  pelvis,  495. 
definition  of,  413. 
extraction  of  child  after,  41 9. 
forceps  in,  419. 

Hodge's  craniotomy  scissors  in,  415. 
in  brow  presentations.  197. 
in  contracted  pelvis,  494,  497,  499,  503,  610, 

513,  519,  521,  528,  533. 
indications  for  perforation  in,  413. 
in  fixce  presentations,  418. 
in  multiple  pregnancy,  235. 
in  rupture  of  uterus,  617. 
instruments  used  in,  414,  420. 
in  uterine  myoma,  545. 
Lusk's  cephalotribe  in,  422. 
operation  of  perforation  in,  414,  428. 


758 


INDEX. 


Craniotomy : 

Scanzoni's  cephalotribe  in,  421. 

Simpson's  cranioclast  in,  425. 

Simpson's  perforator  in,  414. 

Smellie's  scissors  in,  415. 

speculum  in,  428. 

Taylor's  forceps  in,  414. 

Thomas's  perforator  in,  415. 

trephine  perforator  in,  41G,  419. 

version  after,  430. 
Craniotractor,  426. 
Cranium,  fetal,  70,  165. 

base  of,  165. 

fontanelles  of,  70,  165,  ISO,  183. 

premature  ossification  of,  551. 

sutures  of,  70,  165. 

vault  of,  165. 
Cravings,  morbid,  in  precrnancy,  91,  118. 
Cream,  use  of,  in  artificial  feeding,  257. 
('rede's  incubator,  357. 
Credo's  method  of  placental  expression,  220. 

in  abortion,  324. 
OristcB  vaffince,  10,  105. 
Crotchet,  429. 

delivery  of  trunk   after  craniotomy  with, 
430. 
Cul-dt-mc  of  Douglas,  9,  15. 
Cuneiis,  2. 
Cunnus^  2. 
Curette,  in  abortion,  317,  320.  324,  326. 

in  mole,  302. 

in  puerperal  fever.  694. 

in  puerperal  lifemorrhage,  592. 
Cyanosis  neonatorum^  68  (tide  asphyxia  neo- 
natorum). 
Cystitis,  in  puerperal  state,  252. 
Cystocele : 

atresia,  vaginal,  from,  537,  623. 

obstructing  labor,  537,  623. 
Cysts : 

in  hydatidiform  mole,  298,  299. 

of  cord,  297. 

of  ovary,   differentiated   from   pregnancy, 
101,  550. 

of  placenta,  289. 

of  uterine  myoma,  542. 
of  vaginal  walls,  538. 

Deafness,  in  pregnancy,  91. 
Death : 

delivery  of  child  in,  650. 

fetal,  causing  abortion,  308. 
diagnosis  of,  106. 

real  or  apparent,  of  mother  in  pregnancy  or 
labor,  650. 

sudden,  in  labor  and  childbed,  645. 
Decapitation : 

after  failure  of  version,  413,  617. 

Braun's  decollator  in,  433. 


Decapitation : 

in  embryotomy,  432. 

methods  of,  432. 

Pajot's  method  of,  434. 
Deeidua,  51,  53,  124,  125. 

diseases  of,  284. 
producing  abortion.  308,  309. 

tatty  degeneration  of,  125. 

glands  of,  125. 

in  extra-uterine  jiregnancy,  329. 

rejlexa,  54,  123,  125,  286. 

reparation  of,  in  puerperal  state,  241. 

serotiiia,  54,  125,  242. 

vera,  .53,  123,  125,  286. 
Decollator.  Braun's,  433. 

use  of,  in  decapitation,  433. 
Deformities,   pelvic,  465   {vide  pelvis,   con- 
tracted). 

absence  of  symphysis,  534. 

contracted  pelvis,  465. 

exostosis,  533. 

liattened  pelvis,  465,  469,  474,  512. 

fractures,  533. 

funnel-shaped  pelvis,  528. 

generally  contracted  pelvis,  477. 

in-egular  forms  of  contracted  pelvis,  478, 
533. 

kyphotic  pelvis,  479,  519. 

Naegele  oblique  pelvis,  514. 

osteomalacic  pelvis,  529. 

pscudo-osteomalacic  pelvis,  478,  533. 

rachitic  pelvis,  475,  478. 

Eobcrt's  anchylosed  and  transversely  con- 
tracted pelvis,  523. 

Scolio-rachitic  pelvis,  521. 

Spondolistlietic  pelvis,  525. 
Degeneration : 

adipoccrous,  of  foetus,  304,  306. 

calcareous,  of  cord,  298. 

caleaieous,  of  tetus,  306. 

fatty,  of  fa-tus,  306. 

hydatidiform,  of  placenta,  298. 

placentid,  299. 
Delirium,  in  emcsis  of  pregnancy,  118. 

in  labor,  701. 
Delivery  : 

care  of  patient  atter,  224. 

forceps,  preparations  for  use  of,  in,  366. 

immature,  307. 
treatment  of,  326. 

premature,  307. 
treatments  of,  319. 
Dermoid  cysts  of  ovary,  550. 
Descent  of  foetus,  in  normal  labor,  171. 

in  face  presentation,  186. 
Desquamation  of  new-born,  250. 
Development : 
of  abdomen,  64. 
of  air-passages,  48. 


INDEX. 


759 


Development : 
of  allantois,  63. 
of  amnion,  63,  64. 
of  anus,  63. 
of  back,  63. 
of  blood,  48. 
of  blood-vessels,  48. 
of  bones,  48,  64. 
of  brain,  48. 
of  cerebellum,  50. 
of  cerebral  vesicles,  63. 
of  cerebrum,  50. 
of  chorion,  64. 
of  clitoris,  64. 
of  cloaca,  48. 
of  cord,  63,  64. 
of  corium,  48. 
of  digestive  tract,  48. 
of  dorsal  plates,  49,  62. 
of  ear,  63,  64. 
of  epidermis,  48. 
of  extremities,  63,  64. 
of  eyes,  63,  64. 
of  face,  64. 
of  M,  65. 
of  foetus,  48,  62. 
of  fontanelles,  64. 
of  genito-urinary  organs,  48. 
of  glands,  48. 
of  hair,  48,  64,  65. 
of  head,  63,  64,  65. 
of  intestine,  48,  50,  63. 
of  jaws,  64. 
of  labia,  64. 
of  lanugo,  64,  65. 
oflips,^64. 
of  lungs,  48. 
of  medulla,  50. 
of  mouth,  48,  63,  64. 
of  muscles,  48. 
of  nails,  48,  64,  65. 
of  navel,  65. 
of  neck,  64. 
of  nerves,  spinal,  48. 
of  nervous  system,  50. 
of  nose,  48,  64. 
of  ovum,  35,  62. 

of  organs  of  generation,  female,  29. 
of  palate,  64. 
of  penis,  64. 
of  placenta,  64. 
of  rectum,  63. 
of  ribs,  64. 
of  scalp,  64. 
of  scrotum,  64,  65. 
of  skin,  48,  64. 
of  .skull,  64. 
of  spinal  column,  48. 
of  stomach,  48,  50. 


Development : 

of  testicle,  65. 

of  thorax,  64. 

of  umbilical  vesicle,  63,  64. 

of  uterus,  30. 

of  vagina,  30. 

of  vernix,  65. 

of  vertebrae,  49. 

of  viscera,  abdominal  and  thoracic,  48,  62. 

of  visceral  arches,  63. 
Diabetes,  complicating  pregnancy,  274. 
Diameters  of  pelvis,  150  etseg.,  169. 

bis-iliac,  151,  468. 

conjugate,  151,  469,  470. 

diagonal  conjugate,  469,  470. 

oblique,  152,  469. 

transverse,  151,  471. 
Diameters  of  fetal  head,  166  et  seq. 
Diarrhoea,  in  pregnancy,  90,  118. 

in  puerperal  fever,  678. 
Diet,  in  pregnancy,  112,  114,  117. 

in  puerperal  state,  253. 
Digestion : 

disorders  of,  in  pregnancy,  90,  93,  114, 116. 

of  new-born  infant,  250. 
Digestive  tract,  development  of,  48. 
Digital  examination  in  labor,  207. 
Digitalis,  use  of: 

in  eclampsia,  581. 

in  hemorrhage,  591. 

in  pneumonia,  270. 

in  puerperal  fever,  697. 

in  shock,  650. 

in  tardy  labor,  457. 
Dilator,  Harnes's: 

in  accidental  haemorrhage,  604. 

in  breech  presentations,  204. 

in  craniotomy,  414. 

in  eclampsia,  580. 

in  hydatidiform  mole,  302. 

in  placenta  praevia,  602-605. 

in  prolapsed  funis,  631. 

in  protracted  first  st^ge  of  labor,  457,  458, 
514. 

in  Thomas's  operation,  449. 

in  vaginal  thrombus,  627. 

to  induce  premature  delivery,  353. 
Dilator,  Gill  Wylie's,  use  of,  127. 
Diphtheritic  patches  in  puerperal  fever,  656, 

657,  686. 
Discus  proligerus^  37,  38,  39. 
Diseases    complicating    pregnancy,    91,    113, 
261   (vide  pregnancy,  diseases  compli- 
cathig). 

albuminuria,  91. 

amaurosis,  91. 

amblyopia,  91. 

amniotic  fluid,  deficiency  of,  293. 

anaemia,  114. 


760 


INDEX. 


Diseases  complicating  pregnancy : 
anassthesia,  91. 
anomalies  of  cord,  293  et  seq. 
anteflexion,  11 G,  278. 
anteversion,  80,  278. 
ascites,  95. 

cardiac  diseases,  89,  266. 
ccpLalaljjia,  122. 
cholera,  263. 
chorea,  114,  274. 

circulation,  disorders  of,  114,  115. 
coiling  of  cord,  2C4,  215,  296. 
constipation,  88,  90,  116. 
cord,  anomalies  of,  293. 
cysts  of  cord,  297. 
deafness,  91. 
death  of  foetus,  106. 
degenerations  of  cord,  297. 
diabetes,  274. 
diarrhoea,  90. 
dizziness,  91. 
dropsy,  88,  114,  116. 
dyspnoea,  90,  114. 
emesis,  93,  99,  116,  117. 
emphysema,  270. 
empyema,  270. 

endometritis  decidua,  284^286. 
exanthemata,  261. 
face-ache,  91,  122. 
flatulence,  112. 
gangrene,  115. 
goitre,  89. 
heartbura,  112,  121. 
heart-disease,  89,  266. 
hernias  of  cord,  296. 
bydatidiform  mole,  298. 
hydrsemia,  89,  115. 
hydramnion,  95. 
hypertrophy  of  heart,  89. 
hysteria,  114. 
icterus,  206. 

incontinence  of  urine,  88. 
indigestion,  90,  93,  114,  116. 
insanity,  114. 
maceration  of  foetus,  804. 
malarial  fever,  122,  264. 
mania,  91,  114. 

mummification  of  foetus,  303,  306. 
nausea,  90,  93,  99,  116,  117. 
neuralgia,  88,  91,  114. 
oedema,  88,  114,  115. 
osteopliytes,  89. 
palpitation,  114. 
paresis,  91. 

pelvis,  contracted,  465. 
phthisis  pulmonalis,  270. 
placental  diseases,  287. 
plethora,  88. 
pleurisy,  270. 


Diseases  complicating  pregnancy : 
pneumonia,  acute  lobar,  2G9. 

prolapse  of  uterus  and  vagina,  282,  283. 

pruritus,  91,  121. 

relapsing  fever,  264. 

retroflexion,  116,  279,  307,  310. 

retroversion,  116,  279. 

rubeola,  261. 

salivation,  90,  94,  99,  118,  121. 

scarlatina,  262. 

small-pnx,  261. 

syncope,  91,  114,  118. 

syphilis,  271. 

tumors,  uterine,  542. 

typhoid  fever,  264. 

typhus  fever,  264. 

varicose  veins,  88,  115. 

variola,  261. 

vertigo,  91,  114.  118. 

vomiting,  93,  99,  116,  117,  359. 
Diseases  of  childbed,  053. 
Diseases,  relations  of  zymotic,  to  puerperal 

fever,  685. 
Di.splacemeuts   of  uterus,    80,  110,  278,  279 
et  seq.,  310  {vide  uterus,  displacements 
of). 
Dizziness  in  pregnancy,  91,  114,  118. 
Dolores  prescujieiites  124,  127,  131. 
Dorsal  plates,  49,  62. 
Double  uterus,  34,  277,  540. 
Douglas,  cul-de-sac  of,  9,  15. 
Douche,  uterine : 

in  abortion,  320,  322-325,  354,  356. 

in  hydatid  mole,  302. 

in  post-part  urn  hi^morrhage,  589. 

in  puerperal  fever,  688,  693,  694. 

in  retained  placenta,  594. 
Douche,  vaginal : 

in  abortion,  320.  322. 

in  Ca'sarean  section,  440. 

in  forceps  deliveries,  367. 

in  placenta  previa,  603,  606. 

in  pregnancy,  113. 

in  protracted  first  st.age  of  labor,  457,  458, 
502. 

in  pruritus,  122. 

in  puerperal  fever,  699. 

in  puerperal  htemorrhage,  592. 

in  puerperal  st.ite,  224,  253,  693. 

in  retained  placenta,  594. 

to  prevent  puei-peral  fever,  687,  688,  692, 
699. 

to  produce  abortion  or  premature  delivery, 
354,  356. 
Dress,  in  pregnancy,  113. 
Dropsy : 

complicating  presnancy,  88,  114,  115. 

of  amnion,  75,  95,  103,  124,  290,  561. 
obscuring  pregnancy,  95. 


nfDEX. 


761 


Dry  labor,  455. 
Ducts : 

lactiferous,  247. 

ofMiiUer,  30. 

Wolffian,  29. 
Ductus  arteriosus,  66,  68,  250. 

after  birth,  250,  038. 
Ductus  Teiiosus,  06,  637. 
Duration  of  pregnancy,  106. 
Duvemey,  tflands  of,  0. 

])yspna;a,  in  pregnancy,   'JO,   114,  292,  351, 
549,  567. 

in  pulmonary  emboli?m,  647,  048. 
Dystocia,  555,  556  et  seq.  {vide  labor,  painful, 
obstructed,  and  tardy). 

from  double  monsters,  556. 

from  fetal  emphysema,  555. 
Dysuria,  from  retroflexion  of  gravid  uterus, 
with  incarceration,  280. 

in  cystocele,  537. 

in  extra-uterine  pregnancy,  339. 

Ears,  development  of,  63,  64. 
Echinococci,  vaginal  atresia  from,  538. 
Eclampsia,  507. 

abortion  in,  578. 

albuminuria  in,  567, 

anaesthetics  in,  579. 

bath,  hot,  in,  580. 

bleeding  in,  579. 

bromides  in,  578  et  seq. 

cathartics  in,  578. 

cerebral  anaemia  in,  575. 

chloral  in,  578  et  seq. 

chloroform  in,  579  et  seq. 

clinical  history  of,  567. 

definition  of,  567. 

dilator,  Barnes's,  in,  580. 

etiology  of,  570. 

forceps  in,  368,  375,  581. 

fi-equency  of,  567. 

in  cholera,  264. 

in  chronic  nephritis,  273. 

in  placenta  prtevia,  599. 

ill  post-part  urn  hemorrhage,  590. 

in  uterine  tumors,  543. 

mania  in,  702. 

morphia  in,  579. 

oedema  of  brain  in,  574. 

pathology  of,  570. 

phlebotomy  in,  579. 

prognosis  in,  569. 

symptoms,  premonitory,  of,  567. 

terminations  of,  569. 

treatment  of,  577. 

uraemia  in.  571,  576. 

urine  in,  569,  577. 

venesection  in,  579. 
£crasevr,  Hicks's  wire,  in  cephalotomy,  431. 


Bcraseur  : 

in  embryotomy,  434. 

in  Porro's  operation,  444. 

in  uterine  myoma,  545. 
Ectopia  of  abdominal  organs  obstructing  la- 
bor, 556. 
Elastic  stockings  in  pregnancy,  116. 
Elbow,  diagnosis  of  knee  from,  199. 
Electricity  : 

in  emesis  of  pregnancy,  117. 

in  extra-uterine  pregnancy,  345. 

in  induced  labor,  355. 

in  post-jmrtum  hemorrhage,  588. 
Elytrotomy  in  extra-uterine  pregnancy,  346. 
Emaciation  in  pregnancy,  114,  118. 
Embolism,  pulmonary,  045. 
Embolus,  pulmonary : 

collapse  and  death  from  pulmonary,  in  la- 
bor and  childbed,  645. 

ether,  in  treatment  of,  650. 

in  puerperal  fever,  66u,  6S0. 

symptoms,  647. 

treatment,  650. 
Embryo : 

anatomy  of,  50,  62. 

circulation  of  60-08. 

development  of,  48. 

layers  of,  47,  48,  62. 

nourishment  ot,  50. 
Embryology,  62. 
Embryonic  area,  47,  48,  62. 
Embryonic  spot,  02. 
Embryotome  of  P.  Thomas,  434. 
Embryotomy,  413,  431. 

decapitation  in,  432. 

exenteration  in,  432. 

indications  for,  431. 

version  in,  432. 
Emesis : 

anodynes  in,  117,  119. 

induction  of  abortion  for,  118,351,  359. 

in  hydramnion,  292. 

m  incarceration  of  I'elroflexed  uterus,  280, 
359. 

in  pregnancy,  93,  99,  116,  117,  567. 
treatment  of,  116,  118. 

in  puerperal  fever,  674,  678. 

in  rupture  of  uterus,  015. 

in  shock,  649. 

narcotics  in,  119. 
Emphysema : 

abortion  in,  270. 

complicating  pregnancy,  270. 

fetal,  causing  dystocia,  555. 

subcutaneous,  in  precipitate  labor,  453. 

subperitoneal,  in  rupture  of  uterus,  616. 
Empyema : 

complicating  pregnancy,  270. 
Encephalocelc,  congenital,  553. 


762 


INDEX, 


Endocarditis : 
in  pregnancy,  267. 
in  puerperal  fever,  669. 
Endochorion,  53. 

Endocolpitis,  in  puerperal  fever,  656,  671. 
Eudometritiis,  cervical,  539. 
Endometritis    decidua^    complicating    preg- 
nancy, 272,  284,  310. 
Endometritis  de:idua  catarrhalis^  or  hydror- 

rTicaa  gravidarum^  286. 
Endometritis  decidua  chronica  diffusa^  284. 
Endometritis  decidua  poli/posa^  285. 
Endometritis  decidua  tuberosa,  285. 
Endometritis  in  puerperal  fever,  656,  657,  671. 
Enema,  an  eclampsia,  580. 
in  labor,  208. 

nutritive,  in  pregnancy,  114.  118. 
post-partum,  254. 
Epiblast,  46-48,  50. 
Epiblastic  spheres,  46. 
Epidermis,  development  of,  48. 

m  maceration  of  loetus,  S04. 
Episiotomy,  214. 

Epithelium,  cylindrical,  ciliated : 
in  glands  of  cervix,  19,  81,  95. 
in  glands  of  uterus,  18,  20. 
of  breast,  247. 
of  ovary,  25,  36. 
of  ovum.  37. 
of  tube,  21,42. 
Erectility : 
cervical,  26. 
of  nipple,  88. 

of  Fallopian  tube  (theoretical),  41. 
of  vaginal  bulbs,  5. 
ovarian  (theoretical).  27. 
uterine  (theoretical),  26. 
va'Tinal  (theoretical),  9. 
Ergot : 
contraindications  for,  in  parturition,  461. 
indications   for,   in    parturition,    224,   460, 

607. 
physiological  action  of,  460. 
u.«e  of,  after  normal  labor,  224,  460,  688. 
in  abortion,  320,  321,  323. 
in  Ciesarean  section,  441. 
in  hydatid  mole,  302. 
in  long  second  stage,  460. 
in  parturition,  224,  460. 
in  placenta  prjevia,  603,  606. 
in  post- partt/m  haemorrhage,  585. 
in  protracted  first  stage  of  labor,  457,  458, 
461,  511. 
Ergotin,  for  varicose  veins,  116. 

in  abortion,  323. 
Erosions,  on  cervix,  in  pregnancy,  81,  116, 
120. 
in  puerperal  state,  243. 
treatment  of,  116,  120. 


Erotomania,  702. 

Erysipelas,  how  related  to  puerperal  tcver, 

686. 
Estimation  of  date  of  confinement,  108. 
Ether : 

in  abortion,  322. 

in  anasmia,  cerebral,  590. 

in  Caesarean  section,  4S9. 

in  embolism,  pulmonary,  i  50, 

in  forceps  delivery,  367. 

in  labor,  226. 

in  lacerations,  623. 

in  nausea  of  pregnancy,  117. 

in  pulmonary  embolism  and  shock,  650. 

post-partiim^  623. 
Eunuchs,  female,  genital  organs  of,  156. 
Eustachian  valve,  66,  08,  637. 
Evisceration,  432. 

Evclutio  condiiplicato  corpore,  564,  565. 
Evolution,  spontaneous,  564. 

etiology  of,  564. 

mechanism  of,  565. 

prognosis,  566. 
Examination  of  patient : 

method  of  conducting,  in  labor,  206. 
in  pregnancy,  99. 
Exanthemata  in  pregnancy,  261. 
Exenteration,  in  embryotomy,  432. 
Excavatio  : 

tecto-titerina,  15. 

vesico-iderina,  15. 
Exercise,  in  pregnancy,  113,  122. 
Exhau>tion,  nerve,  and  shock,  648. 

treatment,  650. 
Exochorion,  53. 

Exostosis,  pelvic  deformity  from,  533. 
Expression  of  head,  in  labor,  212. 
Expression  of  placenta : 

by  Crede's  method,  220,  324. 
m  contracted  pelves,  506. 
in  irregular  pains  of  third  stage  of  labor, 

459,  403. 
in  placenta  prtevia,  603. 
Expulsion,  spontaneous,  564. 
Extension,  of  fetal  head,  in  face  presenta- 
tions, 186. 

of  fetal  head,  in  normal  labor,  177. 
External  rotation  : 

in  face  presentations,  188. 

in  normal  labor,  177. 
Extraction  of  fa?tus : 

alter  perforation,  419,  428. 

by  breech,  in  breech  presentations,  385. 

by  feet,  in  breech  presentations.  384. 

by  forceps,  in  breech  cases,  388. 

in  Csesarean  section.  440. 

in  craniotomy,  419. 

in  foot  and  breech  presentations,  382  it  seq. 

in  pelvic  presentations,  382. 


INDEX. 


763 


Extraction  of  fcetus : 

in  real  or  apparent  death  of  mother  in  preg- 
nancy  or  labor,  'J50. 

relief  of  arms  in,  394. 
Extraction  of  trunk  in  breech  cases,  384. 
Extra- uterine    pregnancy    (vide    pregnancy, 
extra-uterine),  280,  3--i7. 

abdominal,  327,  335,  339. 

collapse  in,  338. 

definition  of,  327. 

diagnosis  of,  280,  340. 

electricity  in,  345. 

clytrotomy  in,  346. 

haemorrhage  in,  327,  346. 

interstitial,  332. 

ovarian,  327,  328,  338. 

peritonitis  in,  339,  340. 

secondary,  339. 

symptoms  of,  338. 

terminations  of,  327,  333,  339. 

tubal,  327,  328. 

tubo-abdominal,  338. 

tuboovarian,  338. 

treatment  of,  343. 

(a)  in  cases  of  early  gestation,  343. 

(b)  in  cases  of  advanced  gestation.  346. 

(c)  in  cases  of  gestation,  after  death  of 
foetU'^,  348. 

Eyes,  development  of,  63,  64. 

Face-ache  in  pregnancy,  122. 
Face,  development  of,  64. 
Face- presentations  (vide  presentations,  face), 
169,  184,  186. 

abnormal  mechanism  of,  188. 

causes  of,  184,  481,  487. 

configuration  of  head  in,  189. 

craniotomy  in,  418. 

descent  in,  186. 

development  of,  64. 

diagnosis  of,  190. 

extension  of  fetal  head  in,  186. 

external  rotation  in,  188. 

flexion  of  foetus  in,  188. 

forceps  in,  381. 

frequency  of,  184. 

heart-sounds  in,  103. 

mechanism  of,  186. 

membranes,  preservation  of,  in,  191. 

mistaken  for  breech,  191. 

perforation  in,  418. 

prognosis  in,  191. 

prolapse  of  cord  in,  630. 

rotation  of  foetus  in,  187. 

treatment  of,  191.  456. 
F;dlopian  tubes,  12,  19,  30. 

ampulla  of,  19. 

anatomy  of,  19,  30. 

cylindrical  ciliated  epithelium  in  21,42  328. 


Fallopian  tubes : 

dilatation  of,  in  atresias,  541. 

fecundation  in,  42. 

fimbnae  of,  19. 

in  extra-uterine  pregnancy,  328. 

infundibulum  of,  42. 

isthmus  of,  19. 

mucous  membrane  of,  21. 

muscles  of,  20. 

non-erectility  of,  41. 

ostium  abdominale  of,  19. 

position  of,  in  pregnancy,  79. 
Famine,  causing  abortion,  308. 
Faradism : 

in  emesis  of  pregnancy,  117. 

in  extra-uterine  pregnancy,  345. 

in  post-partum  hiBmorrhage,  588. 
Fascia,  pelvic,  161. 
Fat,  in  abdominal  wall,  obscuring  pregnancy, 

102. 
Fat,  development  of,  65. 
Fatty  degeneration  of  fcetus,  306. 
Fecundation,  42-44. 

changes  in  ovum  after,  44. 
Feeding,  artificial,  of  infants,  257. 

natural,  of  infants,  254. 
Faeces,  of  infants,  251. 
Fever : 

malarial,  complicating  pregnancy,  264. 
complicating  the  puerperal  state,  653. 

milk,  247. 

puerperal,  653  (vide  puei-peral  fever). 

relapsing,  in  pregnancy,  264. 

scarlet,  complicating  pregnancy,  262. 

typhoid,  in  pregnancy,  264. 

typhus,  in  pregnancy,  264. 
Fibroid    tumors,    differential    diagnosis    of, 
from  pregnancy,  101. 

of  placenta,  290. 
Fillet,  use  of,  in  breech  and  foot  cases,  388, 
391. 

in  version,  411. 
Fimbria? : 

of  Fallopian  tube,  19. 

ovaricce,  42. 
Fissure  of  nipple,  707. 
Fistulae  after  Thomas's  operation,  449. 

caused  by  calculi,  537. 

caused  by  contracted  pelvis,  466,  489,  541 
622. 

caused  by  slow  labor,  368. 
Flattened  pelvis,  465,  469,  474,  512. 

non-rachitic,  474. 

rachitic,  475. 
irregular,  478. 
Flatulence  in  pregnancy,  112. 
Flexion  of  fetal  head : 

advantages  of,  172. 

in  contracted  pelves,  486. 


164: 


INDEX. 


i'lexion  of  fetal  head: 
in  face  presentations,  188. 
in  normal  presentations,  171. 
Floor,  pelvic  or  perineal,  159,  IGO. 
Fluctuation,  uterine,  in  prc<rnaucy,  100. 
iluid,  amniotic,  61. 
anomalies  of,  290. 
composition  of,  61. 
deficiency  of,  293. 
obscuring  pregnancy,  95. 
Foetus : 

abdominal  enlargement  of,  obstructing  de- 
livery, 554. 
abnormalities   of,   obstructing  delivery    of 

trunk,  554. 
abnormalities  of,  obstructing  labor,  551. 
adiiesions  of,  causing  dystocia,  556. 
adipocerous  cliangcs  in  retained,  304,  306. 
anasarca  of,  causing  dystocia.  555. 
anchylosis  of  joints  of,  518,  556. 
ascites  of,  obstructing  delivery,  554. 
at  term,  68,  165. 
attitude  of,  72  et  seq. 
bladder,  dilatation  of,  554. 
causes  of  death  of,  308. 
circulation  of,  G6-68,  250,  637. 
configuration  of,  in  breech  presentations, 

202. 
congenital  hydrocephalus  of,  551. 
cord  of,  anomalies  and  diseases  in,  293. 
cranium  of,  70,  165,  551. 
dead,  retention  of,  in  utero,  302. 
death  of.  106,  308. 

from  torsion  of  cord,  294. 

indicating  abortion,  350. 

in  nephritis,  273. 

producing  abortion,  308. 
degeneration,  adipocerous,  of,  306. 

calcareous,  of,  3<'6. 

fatty,  of,  306. 

of  liver  of,  555. 
descent  of,  in  labor,  171. 
development  of,  62. 

in  successive  months,  62. 

in  first  month,  62. 

m  second  month,  64. 

in  third  month,  64. 

in  fourth  month,  64. 

in  fifth  month,  64. 

in  sixth  month,  65. 

in  seventh  month,  65. 

in  eighth  month,  65. 

in  ninth  month,  65. 

in  tenth  month,  65. 
diagnosis  of  death  of,  106. 
diameters  of  head  of,  1 66  et  seq. 
diseases  of,  obstructing  delivery  of  its  head, 

551. 
ectopia  of  viscera  of,  556. 


Foetus : 
emphysema  of,  555. 

encephaloccle  of,  obstructing  labor,  553. 
extraction  of: 

in  breech  and  foot  presentations,  382  et 
seq. 

in  Csesarean  section,  440. 

in  craniotomy,  419. 

in  pelvic  presentations,  382  et  seq. 

instruments  for,  414,  419. 

with  head  at  brim,  398. 
face  of,  70, 105. 
fatty  degeneration  of,  306. 
liexion  of,  in  labor,  171,  172.  188. 
fontanelles  of,  70,  165,  183,  551. 
funis  of,  anomalies  in,  293. 
habitual   death    of,  as   cause  for  inducing 

abortion,  350. 
head  of,  at  term,  70,  105,  165  et  seq.  {vide 

head,  fetal). 
heart -sounds  of: 

in  asphyxia,  641. 

in  breech  presentations,  105. 

in  face  presentations,  105,  190. 

in  head  presentations,  105,  183. 

in  hydatidiform  mole,  301. 

in  hydramnion,  292. 

in  hydrocephalus,  552. 

in  pregnancy,  96,  97,  101,  103,  106. 

in  tardy  labor,  460. 
hydrocephalus  of,  obstructing  labor,  551. 
hydrothorax  of,  obstructing  hilwr,  554. 
in  extra-uterine  pregnancy,  340. 
in  first  month,  02. 
in  second  month,  64. 
in  third  month,  64. 
in  fourth  to  eighth  month,  65. 
in  ninth  to  tenth  month,  65. 
lanugo  of,  02,  64,  68,  69. 
length  of,  at  term,  69. 
liver  of,  fatty  degeneration  of,  555. 
maceration  of,  304. 
meconium  of,  62,  69,  199,  250. 
monstrosities  developed  from,  556. 
movements   of,   in   pregnancy,  75,  95,  96. 
9S-100,  106. 

active  and  passive,  96. 

in  hydatidiform  mole,  301. 
mummification  of,  303,  306. 
pancreas  of,  enlarged,  555. 
papjjracens,  231. 
positions  of,  72,  76,  170. 

classification  of,  170. 

first,  76. 

in  multipara?,  75. 

in  pluriparse,  75. 

occipito-posterior,  170,  179. 

second,  76. 
presentations  of,  72  {vide  presentations). 


INDEX. 


ro5 


Fo2tus : 
pressure-marks  on  head  of,  490. 
putrefiiotion  of,  iu  retention  of,  303,  305, 

312. 
release  of  arms  of,  394. 
retention,  in-  titfro^  of  dead,  302,  547. 
rotation  of,  in  labor,  173. 
sangui)wleiitus^  304. 
size  of,  in  succe:^sive  months,  02  it  seq. 
spleen  of,  enlargement  of,  555. 
sutures  of,  70,  1G5,  183. 
tumors  of  trunk  of,  obstructing  labor,  554, 

555. 
urine  ot,  61,  250. 
vernix  caseosa  of,  fiS. 
weight  of,  at  term,  69. 
Folds,  medullary,  48. 

Follicles,  Graafian,  23,  35,  36  {dde  Graafian 
follicles), 
sebaceous,  of  areola,  88,  99. 
Fontanelles,  64,  70,  165,  183. 
closure  of,  in  obstructed  labor,  551. 
in  hydrocephalus,  552. 
large,  70,  166. 
small,  70,  166. 
Foot  presentations,  169. 
diagnosis  of,  198. 
extraction  in,  382  et  seq. 
management  of  cord  in,  393. 
Foramen  ovale.,  66,  68,  250. 
after  birth,  250. 
valve  of,  66,  68. 
Foramen,  obturator,  158,  159. 
Forceps,  361. 
action  of,  365. 
after-coming  head,  to,  399. 
anaesthetics  in  application  of,  367. 
application  of,  369,  376. 

to  after-coming  head,  399. 
asphyxia  from,  639. 
at  the  pelvic  brim,  375. 
at  the  pelvic  outlet,  36s. 
blades,  introduction  of,  369,  376. 
breech,  of  Miles,  388. 
Chamberlen's,  361. 
Chapman's,  362. 
contrasted   with  version   and  craniotomy, 

493  et  seq. 
craniotomy  of  Meigs,  modified,  429. 
deliveries  by,  preparation  for,  366. 
douche,  before,  367. 
Hodge's,  365,  420. 
liistory  of,  361. 
in  abortion,  356. 
in  atony  of  uterus,  368. 
in  brow  presentations,  197. 
in  contracted  pelvis,  497,  503,  508.  511  et 

seq. 
in  craniotomy,  419. 


Forceps : 

in  death  of  mother,  651. 

indications  for,  366,  369,  545,  651. 
at  pelvic  outlet,  368. 

in  double  vagina,  538. 

in  eclampsia,  581. 

in  face  presentations,  381. 

in  foot  and  breech  presentations,  388. 

in  heart-disease,  268. 

in  multiple  pregnancy,  235. 

in  occipito-posterior  positions,  379. 

in  placenta  pricvia,  603. 

in  premature  labor,  356. 

in  prolapse  of  funis,  631. 

in  prolapse  of  vagina,  283. 

in  protracted  second  stage  of  labor,  457, 
458,  460. 

in  rupture  of  uterus,  617. 

introduction  of  blades  of,  369,  376. 

in  Thomas's  operation,  450. 

in  vaginal  prolapse,  283. 

in  vaginal  thrombus.  627. 

lacerations  from,  621. 

Levret's,  364. 

locking  of,  372. 

long,  363. 

Lusk's  modification  of  Tamier's,  378,  379. 

Naegele's,  364. 

operation  of  introduction  of,  369,  376. 

ovum-,  use  of,  in  alwrtion,  324. 

position  for,  367. 

preparation  for  delivery  by,  366. 

removal  of,  374. 

selection  of,  362,  365. 

short,  362. 

Simpson's,  364,  379. 

S'l'ellie's,  363. 

Tarnier's,  377,  390,  400,  513,  .'^81. 

Tarnier's,  modified  by  Lusk,  378.  379. 

Taylor's,  at  brim,  377,  513. 

Taylor's  narrow-bladed,  377,  414. 

time  for  application  of,  309. 

traction  on,  direction  of,  366,  372,  373,  377. 

volsellar  432. 

"Wallace's,  365. 

White's.  305. 
Forces,  expellent,  action  of,  135. 

anomalies  of,  452. 
Fornix,  9,  613. 

laceration  of,  621. 
Forehead,  spots  on,  in  pregnancy,  91. 
Fourchette,  4. 

Fov.ier's  solution  in  nausea,  117. 
Fractures,  caused  by  contracted  pelvis,  491. 

causing  pelvic  deformities,  533. 
Frenulum  clitoridis,  4. 
frenulum.  viilva.i  4. 
in  pregnancy,  105. 

laceration  of,  iu  labor,  134. 


'60 


INDEX. 


Ftaiidus  of  uterus,  12. 
development  of,  30. 
Fungi  in  milk,  258. 
Funic  souffle,  98. 

Fimis,  60,  64  (vide  cord,  umbilical), 
anomalies  of,  293  ei  seq. 
arteries  of,  60,  61. 
calcareous  degeneration  of,  298. 
care  of,  in  abortion,  326. 

in  infants,  256. 
coiling  of,  204,  215,  296. 
cysts  in,  297. 
diseases  of,  297. 
expression  of,  630. 
formation  of,  60. 
fully  developed,  61. 
gelatin  of,  61. 
iiiemorrbage  from,  453. 
hernias  of,  296. 
in  puerperal  state,  250. 
knots  in,  295. 

laceration  of,  in  precipitate  labor,  453. 
length  of,  61. 
ligation,  late,  of,  216. 
management  of,  in   breech   presentations, 

393. 
marginal  insertion  of,  298. 
presentation  ot,  629. 
prolapse  of,  510,  561,  629. 

diagnosis  of,  630. 

in  breech  cases,  204. 

prognosis  of,  630. 

treatment  of,  631, 

postural,  632. 

reposition  of,  631  ei  seq. 

by  instruments,  634. 

by  postural  treatment,  632. 
shortness  of,  causing  dystocia,  559. 
-souffle  in,  98. 
stenosis  of  vessels  of,  297. 
structure  of,  61. 
torsion  of,  293. 
tying,  in  labor,  215,  236. 
vein  of,  60,  61.  ♦ 

vessels  of,  60,  61. 
Funnel-shaped  pelvis,  528. 

Gait,  feminine,  154. 

Galactocele,  712. 

Galacton-hoea,  706. 

Galvanism,  in  extra-uterine  pregnancy,  345. 

Galvanization  to  produce  premature  labor, 

355. 
Gal vano  -  cautery,    in    Thomas's    operation, 

451. 
Ganglion,  cervical,  27,  77,  126,  127. 

in  pregnancy,  77,  127. 
Gangrene,   from    oedema  of   pregnancy   and 

labor,  115,  536. 


Gastrotomy  (tide  Ciesarean  section) : 
in  puerperal  peritonitis,  699. 

in  uterine  rupture,  618. 
Gauze,  iodoform,  in  puerperal  state,  688. 
Gelatin  of  Wharton,  61. 
Gelseniium,  in  face-ache,  122. 
Generation  : 

anatomy  of  female  organs  of,  1. 

development  of  lemale  orgau.s  of,  29,  48. 
Genital  canal : 

atresia  of,  535. 
symptoms  of,  541. 

ruptures  of,  610  {ride  lacerations). 

uterine  atresia  of,  539. 

vaginal  atresia  of,  536. 

vulvar  atresia  of,  535. 
Germinative  spot,  39. 
Germinative  vesicle,  39,  45. 

disappearance  of,  45. 
Germs  in  puerperal  fever  : 

bacteria,  666  et  seq.,  681,  689. 

micrococci,  666  etseq.,  681,  689. 
Gill  Wylie's  treatment  of  emesis,  120. 
Glandulm  vestibulares  : 

majores,  6. 

minores,  5. 
Glands : 

Bartholin's,  6. 

cervical,  19. 

decidual,  125. 

Duverney's  6. 

labial,  5. 

mammary,  anatomy  and  chancres  of,  in 
pregnancy,  87,  88,  90,  94,  99,  105,  106, 
247. 

mucous,  of  the  vulva,  5. 

salivary,  activity  of,  in  pregnancy,  90,  94, 
99,  118,  121. 

sebaceous,  of  the  nympha?,  5. 
of  areola,  88. 

thyroid,  changes  in,  during  pregnancy,  89. 

uterine,  18. 
pod-paHum,  242. 

vaginal,  10,  162. 

vulvar,  5,  162. 
Glans  clitoridis,  3. 
Goitre,  in  pregnancy,  89. 
Graafian  follicles,  23,  35,  36. 

developed,  38. 

discuf  prolic/erus  in,  37.  38. 

macula  of,  39. 

memhrana  r/ranvlosa  of,  37« 

memhrana  propria  of,  37. 

number  of,  38,  39. 

stigma  of,  39. 

theca  follimli  of,  36,  38. 

tunica  fihrosa  of,  36,  38. 

tunica  propria  of,  30,  38. 

young,  38. 


INDEX. 


767 


I 


Gravid  uterus : 

anteflexion  of,  116,  278. 

anteversion  of,  80,  278. 

hernia  of,  283. 

prolapse  of,  282,  359. 

retroflexion  of,  116,  279,  369. 
with  incarceration,  280,  359. 
treatment  of,  280. 

retroversion  of,  116,  279. 
Gravitation,  causing  head  presentations,  74. 
Groove,  primitive,  48. 
Guarana,  in  cephalalgia,  122. 
Gummata,  placental,  290. 

Ilwmatoma : 

in  uterine  rupture,  615. 
Hremoglobin  in  pregnancy,  89. 
Hair,  development  of,  48,  64,  65. 
Hallucinations,  in  emesis  of  pregnancy,  118. 
Hand,  selection  of,  for  version,  406,  407. 
Haamatocele,  in  extra-uterine  pregnancy,  339. 
Hematoma  tubce,  339. 

vulvar,  536. 
Hsemorrhage : 
accidental,  594,  597,  60G. 
concealed,  600. 
external,  606. 

forceps  indicated  by,  366,  375. 
from  cervical  laceration,  620. 
from  normally  implanted  placenta,  603. 
in  abortion,  309,  311,  312,  313,  319,  320,  325, 

326. 
in  Cuesarean  section,  control  of,  440. 
in  contracted  pelvis,  488,  491. 
ill  extra-uterine  pregnancy,  327,  338,  339. 
in  labor,  third  stage  of,  134. 
in  multiple  pregnancy,  236. 
in  placenta  praevia,  597,  599,  601,  605. 
internal,  606. 

in  Thomas's  operation,  449,  451. 
in  uterine  cancer,  547. 
in  vaginal  thrombus,  627. 
post-partuTn,  249,  581. 
anodynes  in.  585. 
armamentarium  for,  585. 
astringents  in,  587,  622. 
causes  of,  279,  569,  583,  620,  622,  627. 
chlorofoi-m,  efl'ept  of,  on,  227,  623. 
disturbances  of  contractility  as  cause  of, 

583. 
disturbances  of  retractility  as  cause  of, 

584. 
disturbances  of  thrombus  formation,  caus- 
ing, 584. 
electricity,  use  of,  in,  588. 
ergot  in,  461. 

in  contracted  pelvis,  492,  495. 
in  double  uterus,  278. 
in  fevers,  264. 


Haemorrhage : 

in  forceps-deliveries,  372. 

in  hydramnion,  292. 

in  lacerations,  620. 

in  multiple  pregnancy,  236. 

in  placenta  prsevia,  601,  605. 

in  premature  labor,  309,  311,  312,  313,  319, 
325,  326,  339. 

in  precipitate  labor,  453. 

intra-uterine  injections  in : 
of  iodine,  587. 
of  iron,  587. 

in  uterine  tumors,  542,  543,  547. 

methods  of  producing  uterine  contractions 
in,  585. 

methods  of  producing  uterine  retractions 
in,  589. 

normal  agencies  for  checking,  582. 

outlying  causes  of,  5y4. 

symptoms  of,  589. 

transfusion  of  blood  in,  590. 

transfusion  of  milk  in,  590. 

treatment  of,  461,  585,  622,  627. 

treatment  of  cerebral  anaemia  in,  589. 
pueqieral,  592. 

astringents  in,  592. 

treatment  of,  592. 
unavoidable,  597,  606. 
vinegar  in,  588. 
Haemorrhoids,  in  pregnancy,  88,  115,  130. 

in  puerperal  state,  254. 
Head,  fetal,  70,  165. 
after-coming,  forceps  applied  to,  399. 

perforation  of,  418. 
articulations  of,  with  spine,  168. 
at  term,  165. 
base  of,  165. 
circumference  of,  168. 
configuration  of,  in  breech  presentations, 
200,  396,  399. 

in  brow  presentations,  194. 

in  contracted  pelvis,  489. 

in  face  presentations,  189. 

in  vertex  presentations,  180. 
descent  and  extension  of,  in  face  presenta- 
tions, 186. 
descent  and  flexion  of,  in  labor,  171,  486. 
development  of,  63-65. 
diameters  of,  166  et  seg. 
diseases  which  obstruct  delivery  of,  551. 
entrance  of,  into  pelvis,  171. 
extension  of,  in  labor,  177. 
external  rotation  of,  in  face  presentations 

188. 
external  rotation  of,  in  labor,  177. 
extraction  of,  in  breech  cases,  396,  398. 
flexion  of,  in  face  presentations,  188. 
fontanelles  of,  64,  70,  165,  183. 
molding  of,  in  vertex  presentations,  179. 


768 


INDEX. 


Head: 
positions  of,  170. 
pret>eutations,  V2-75,  168. 

heait-sounds  in,  103. 
restitution  of,  178. 
rotation  of: 
in  breech  presentations,  199,  395. 
in  brow  presentations,  194. 
in  face  presentations,  103, 187. 
in  normal  labor,  173. 
in  vertex  presentations,  173. 
scalp-tumor  on,  181,  190,  194  (vide  caput 

succedaneum). 
sinking  of,  105. 
sutures  of,  1G5. 
vault  of,  1(55. 
Headache  in  pregnancy,  122. 
in  eclampsia,  567,  509. 
post-partum,  24S. 
Heart : 
diseases  of,   complicatiug   pregnancy,   89. 

266,  310,  351,  359. 
hypertrophy  of,  in  pregnancy,  89. 
sounds,  fetal,  iu  iireguaucy,  96,  97,  101, 103, 
106,  342,  460,  641. 
disappearance  of,  in  pregnancy,  105. 
effect  of  pains  on,  97. 
frequency  of,  in  the  sexes,  97. 
maximum  intensity  of,  98. 
in  hydramnion,  292,  293. 
in  hydrocephalus,  552. 
Heart-burn  in  pregnancy,  121. 
Hemicephalus,  559. 

Hemisjjheres,  cerebral,  development  of,  50,  63. 
Hernia : 
congenital,  550. 
of  cord,  296. 
of  gravid  uterus,  283. 
of  vagina,  atresia  from.  537. 
of  vulva,  538. 
Hiatus  sacral  is,  142. 
Hilum,  of  ovary,  22. 
Hips,  Avidening  of,  in  pregnancy,  86. 
Hodge's  forceps,  365,  420. 
Hook: 

blunt,  388,  393,  430. 
in  breech  and  foot  cases,  388,  393. 
in  craniotomy,  430. 
Braun's  decapitating,  433. 
Ramsbotham's  decapitating,  434. 
Taylor's,  430. 
Hospitals,  maternity,  686  et  seq. 
Hottentot  apron,  4. 

Hour-L'lass  contraction  of  uterus,  224,  462. 
Hydatidiforin  mole,  231,  298. 
abortion  in,  301. 
anatomy,  morbid,  of,  298. 
diagnosis  of.  301. 
etiology  of,  300. 


Hydatidiform  mole : 

prognosis  ot,  301. 

symptoms  of,  301. 

treatment  of,  302. 
Hydatids,  pelvic,  causing  atresia,  538. 
Hydraemia  of  pregnancy,  89,  115,  280,  574. 
Hydramnion,  75,  95,  103,  2'dO. 

as  cause  for  abortion,  124. 

as  cause  of  precipitate  labor,  292. 

as  cause  of  tardy  labor,  455,  584. 

diagnosis  of,  293. 

etiology  of,  290. 

indicating  abortion.  351. 

in  hydioceplialus,  .552. 

obscuring  pregnancy,  95,  103. 

prognosis  of,  293. 

symptoms  and  signs  of,  292. 

treatment  of,  293,  456. 
in  labor,  456. 
Hydrocephalus,  551. 

causing  uterine  rupture,  612. 

diagnosis  of,  552. 

etiology  of,  5.''.2. 

following  premature  labor,  349. 

mechani.-ni  of  labor  in,  553. 

morbid  anatomy  of,  552. 

prognosis  in,  553. 

treatment  of,  553. 
HydroiThaia  gravidarum,  286. 
Hydrotliorax,  fetal,  obstructing  labor,  554. 
Hygiene  of  i)rcgnancy,  112. 
Hymen : 

anatomy  of,  6. 

annularis,  7. 

atiesia  of,  535. 

cribj'ijormis,  7. 
fimhriatus,  7. 

imperforatus,  7. 

in  pregnancy,  105. 

in  puerperal  state,  249. 
Hyoscyamus  in  insomnia,  122. 
Hypertemia,  venous,  in  pregnancy,  115. 
Hyperosmia  in  pregnancy,  118. 
Hypertrophy,  of  uterine  mucous  membrane, 

causing  abortion,  310. 
Hypnotics  in  pregnancy,  122. 
Hypoblast,  47,  48,  50. 
Hypobla^tic  spheres,  46. 
Hysterectomy,  for  myoma,  544. 
Hysteria,  in  pregnancy,  114,  708. 
Hysterotomy,  424  (vidt  Cesarean  section). 

in  hernia  of  uterus,  284. 

Ice,  use  of,  in  nausea  of  pregnancy,  117,  119. 

in  haemorrhage,  587,  588. 

in  mastitis,  711. 

in  puerperal  fever,  698. 
Icterus : 

abortion  in,  266. 


INDEX. 


TOO 


Icterus : 

in  pregnancy,  266. 

neonatorum,  219,  250. 
Ileus,  due  to  retroflexed  gravid  uterus,  280. 
Ilia,  anatomy  of,  142,  143,  150,  468. 
Ilio-pectineal  line,  144. 
Imperforate  anus,  250,  296. 
Impregnation,  42-44  {vidu  fecundation). 
Incarceration   of   retrofle.xcd  gravid   uterus, 
116,  279,  359. 

of  prolapsed  uterus,  282. 

treatment  of,  280,  316,  359. 
Incisions,  vulvar,  in  labor,  214. 
Incontinence  of  urine  in  pregnancy,  88,  279. 
Incubator : 

Crede's,  357. 

Tarnier's,  353. 
Indigestion  in  pregnancy,  88,  90,  114. 
Inertia  uteri,  454. 

causes  of,  282,  292,  455,  598. 

treatment  of,  456. 
Infant,    new-born,    250     {vide    newly    born 
child). 

artificial  feeding  of,  257. 

bath  of,  25G. 

bottle  for,  259. 

breasts  of.  250. 

cafut  succedaneum  of,  181,  190,  250. 

cardiac  ventricle  of,  250. 

care  of,  256,  356. 

care  of  bottle  of,  259. 
of  cord  of,  256. 

changes  in  circulation  of,  216,  250. 

circulation  of,  affjcted  by  thoracic  as^sira- 
tion,  218. 

cord,  late  ligation  of,  in,  216. 

digestion  of,  250. 

ductus  arteriosus  of,  250. 

faces  of,  25L 

foramen  ovale  of,  250. 

icterus  of,  219,  250. 

loss  of  weight  of,  251. 

meconium  of,  250. 

navel  of,  250. 

nursing  of,  254. 

ophthalmia  of,  712. 

selecting  wet-nurse  for,  256. 

skin  of,  250. 

sprue  in,  259. 

tumor  on  presenting  part  of,  250. 

umbilicus  of,  250. 

urine  of,  250,  251. 

weight,  loss  of,  in,  251. 

wet-nurse  for,  '.i56. 
Inforctions,  puerperal,  608. 
Infarctions,  placental,  288. 
Infectious  diseases  complicating  pregnancy, 

260. 
Infundibulum  tuh<z,  42. 
49 


Injections : 
between  uterus  and  ovum,  to  produce  abor- 
tion, 352. 
hypodermic, 
in  anaemia,  cerebral,  590. 
in  embolism,  pulmonai-y,  650. 
intra-uterine,  in  post-partum  haemorrhage, 

587. 
intra-uterine,  in  puerperal  fever,  688,  693, 
694. 
in  puerperal  haemorrhage,  592. 
vaginal, 
after  removal  of  retained  placenta,  594. 
in  protracted  first  stage  of  labor,  457,502. 
to  prevent  puerperal  fever,  687,  688,  692, 

699. 
to  produce  abortion,  354. 
Inoculation,  causing  puerueral  fever,  683. 
lusalivation  in  pregnancy,  90,   94,  99,  118, 

121. 
Insanity : 
in  pregnancy,  91,  114,  701. 
of  lactation,  701,  703. 
puerperal,  701,  703. 
Insertion,  marginal,  of  cord,  298,  630. 
Insomnia  in  pregnancy,  122,  292. 
Insufflation  in  aspTajxia  neonatorum,  643. 
Internal  version,  401,  405. 
Interstitial  pregnancy,  332. 
Intestine : 

development  of,  48,  50,  63. 
Intoxication,  putrid,  666. 
Inversio  uteri,  607. 

treatment,  608. 
Involution,  uterine,  240. 
Iodine,  injection  of,  693. 

in  post-partum  hiiemorrhage,  587. 
Iodoform  gauze,  use  of.  imst  partum,  592,  688, 
7C0.^ 
in  haemorrhage,  589,  592. 
Iodoform  in  pelvic  abscess,  700. 
Iodoform   suppositories,   in   puerjieral   state, 

694. 
Iron  : 
injection  of,  in  post-partum,  haemorrhage, 
587. 
in  puerperal  fever,  693. 
in  puerperal  ha>morrhage,  587. 
in  albuminuria,  577. 
in  chorea,  275. 
in  hydatid  mole,  302. 
in  phlegmasia,  706. 
in  pregnancy,  114,  122. 
Ischia,  anatomy  of,  142,  144. 
spine  of,  145,  153. 
tuberosity  of,  145. 
Ischio-cavernosus,  162,  163. 
Ischuria,  in  vaginal  thrombus,  626. 
Isthmus  of  Fallopian  tube,  19. 


•770 


INDEX. 


Jaundice : 

in  new-born  child,  250. 

in  pregnancy,  266. 
Jaws,  development  of,  64. 
Joints : 

anchylosis  of  letal,  obstructing  labor,  556. 

mobility  of  pelvic,  in  labor,  148,  275. 

pelvic,  145,  275. 

sacro-iliac,  145. 

Kidneys : 

cystic  degeneration  of  fetal,  554. 

diseases  of,  indicating  abortion,  359. 

pathological  changes  of,  in  eclampsia,  569 
et  seq. 
Kiesteine,  94. 

Knee,  diagnosis  of,  from  elbow,  199. 
Knots  in  umbilical  cord,  295. 
Koumyss,  in  emesis  of  pregnancy,  117. 
Kyphotic  pelvis,  479,  519. 

Labia,  changes  in,  during  pregnancy,  86. 

adhesions  of,  535. 
Labia  mojora,  2,  64. 

changes  in,  during  gestation,  86,  104,  105, 
115,  131. 

commissures,  anterior  and  posterior,  of,  3. 

development  of,  64. 

gangrene  of,  536. 

hernia  of,  538. 

oedema  of,  in  pregnancy  and  parturition, 
86,  115,  131,  134,  249,  536,  567,  577. 

thrombosis  of,  5,  536,  625. 
Labia  7ninora^  3. 

sebaceous  glands  of,  5. 

post  partum,  249. 
Labor,  123. 

action  of  abdominal  muscles  in,  129. 

action  of  expellent  forces  in,  135. 

action  of  pains  on  uterine  walls  in,  128. 

action  of  vagina  in,  129. 

aniemia  in,  645. 

anoesthetics  in,  225. 

antisepsis  in,  225,  688  et  seq. 

armamentarium  for,  206. 

bag  of  waters  in,  132. 

bed,  preparation  of,  lor,  206. 

cancer  of  cervix  in,  547. 

catheterization  in,  208. 

causes  of,  123. 

cer\ical  dilatation  in,  131,  137,  139. 

cervical  laceration  in,  131. 

chill  in,  134. 

chloroform  in,  210,  226. 

clinical  course  of,  123,  130. 

collapse  in,  645,  648. 

contraction  of  uterine  ligaments  in,  128. 

contractions,    uterine,    in,   127,   131,   135, 
462. 


Labor : 

painless,  causing  cervical  dilatation,  81, 
130  et  seq. 
cord,  care  of,  in,  215. 
date,  computation  of,  108-111. 
death,  sudden,  in,  645,  650. 
detinition  of,  1 23. 
deliiiuni  in,  701. 
dry,  455. 

duration  of,  135,  207. 
eclampsia  in,  567. 
enemata  in,  208. 
episiotomy  in,  214. 
ergot  in,  224,  457,  458,  4G0,  461,  511. 
ether  in,  226. 
examination  in,  99,  206, 
expulsion  of  trunk  in,  178. 
extension  of  head  in,  177. 
external  rotation  in,  177,  188,  201. 
faintness  in,  134. 
false,  464. 
fever  in,  464. 
forceps  in,  369. 

haemorrhage  in  third  stage  of,  134. 
labia  in,  131. 

laceration  of  frsenulum  in,  134. 
laceration  of  perina?um  in,  134. 
mechanism  of,  140,  168. 

abnormal,  in  vertex  presentations,  179. 

in  abnormal  face  presentations,  188. 

in  breech  presentations,  199. 

in  brow  presentations,  194. 

in  contracted  pelvis,  484,  495,  502. 

in  face  presentations,  186. 

in  irregular    breech   presentations,    201, 
5G4. 

in  noiTnal  presentations,  171. 

in  occipito-posterior  positions,  179. 

witli  monstrosities,  557. 

normal,  171. 

descent  and  flexion  in,  171. 
rotation  in,  173. 
extension  in,  177. 
external  rotation  in,  177. 
restitution  in,  178. 
expulsion  of  tnnik  in,  178. 
metritis  in,  464. 
missed,  304,  S05. 
natural,  169,  171. 
normal,  171,  205. 

anaesthetics  in,  210,  225,  268,  457. 

armamentarium  for,  206. 

bed  in,  206. 

care  of  patient  after,  224. 

chloroform  in,  226,  457. 

conduction  of,  205. 

cord,  care  of,  in,  215. 

delivery  of  shoulders  in,   178,  199,  215, 
396. 


INDEX. 


Yn 


Labor : 

duration  of,  207. 

enema  in,  208. 

examination  of  patient  in,  206. 

nianajrement  of  first  stage  of,  208. 

management  of  second  stage  of,  209. 

management  of  third  stage  of,  220. 

placental  period  of,  134. 

posture  in,  208-210. 

preliminary  preparations  for,  205. 

preservation  of  perinteum  in,  193,  210. 

retention  of  urine  in,  SOS. 

treatment  of  lacerations  after,  224. 

tying  cord  in,  215. 
obstructed,  551  (vide  obstructed  labor), 
cedema  in,  130,  368. 
painful,  463. 

anajsthetics  in,  463. 

cessation  of,  alter  diaphoresis,  463. 

from  hysteria,  463. 

from  inflammation  of  or  around  genital 
organs,  464. 

fiom  intestinal  irritation,  464. 

from  rheumatism,  463. 
painless,  130. 
pains  of,  127,  129,  452. 

contracted  pelvis  affecting,  481. 

influence  of,  on  organism,  130. 
pathology  of,  452. 

pelvis,  contracted,  complicating,  479. 
phenomena,  clinical,  of,  123,  130. 
physiology  of,  123,  127. 
posture  in,  20S-210. 
precipitate,  453. 

consequences  of,  453. 

in  hydramnioft,  292. 

treatment  of,  453. 
prediction  of  date  of,  108-111. 
premature,  307,  349,  500  {vide  abortion). 

care  of  child  after,  356. 

catheterization  of  uterus  to  produce,  351. 

choice  of  methods  to  produce,  356. 

from  puncture  for  oedema  of  pregnancy, 
115. 

in  anaemia  of  pregnancy,  115. 

in  cholera,  264. 

in  heart  diseases,  268. 

indications  for,  349,  500,  578,  600,  616. 

induction  of,  349. 

in  eraesis  of  pregnancy,  119. 

injections  between  uterus  and   ovum  to 
produce,  352. 

mechanical   dilatation  of  cervix  to  pro- 
duce, 353. 

operations  lo  produce,  351. 

rupture  of  membranes  to  produce,  353. 

tampon,  vaginal,  to  produce,  355. 

time  for,  349. 

vaginal  douche  to  produce,  354. 


Labor : 
preparations  for,  205. 
preservation  of  perina^um  in,  210  et  seq. 
pressure  of  uterus  in,  140. 
pulse  in,  130,  464. 

rupture  of  membranes  in,  132,  140,  208. 
stage  of: 

first,  131. 

anesthetics  in,  226. 

anodynes  in,  456. 

bloody  discharge  in,  131. 

influence  of  contracted  pelvis   on,  483, 
495,  502. 

irregular  pains  in,  454. 

management  of,  208,  454. 

pains  in,  131. 

posture  in,  208-210. 

treatment  of  long,  456,  650. 
second,  or  stage  of  expulsion,  133. 

auEesthetics  in,  210,  225. 

forceps  in,  369. 

irregular  pains  in,  459. 

management  of,  209. 

pains  in,  133. 

perinagum  m,  134,  210  et  seq. 

posture  in,  210. 

treatment  of  long,  459. 

urethra  in,  134. 

third  or  placental  period,  134. 
anipsthetics  in,  227. 
atony  in,  458. 
chill  in,  134. 

in  multiple  pregnancy,  232. 
irregular  pains  in,  461. 
management  of,  220,  461. 
symptoms,  precursory,  of,  130. 
syncope  in,  134,  645. 
tardy,  453. 

anodynes  in,  456. 

Barnes's  dilator  in,  457,  458. 

bougies  in,  457. 

causes  of,  455. 

douche,  vaginal,  in,  457,  458. 

ergot  in,  458,  460. 

expression  in,  459. 

hour-glass  contractions  of  uterus  in,  462. 

in  double  uterus,  278. 

irregular  pains  in  first  stage  of,  454. 

irregular  pains  in  second  stage  of,  459. 

irregular  pains  in  third  stage  of,  461. 

quinia  in,  458. 

treatment  of,  456,  459,  462. 

•with  short  cord,  560. 
temperature  in,  130,  464. 
theory  of  causes  of,  127. 
time  of  beginning  of,  108-111,  123. 
tumors,  ovarian,  in,  550. 
tumors,  uterine,  complicating,  542. 
unnatural,  169. 


772 


INDEX. 


Laboi ; 

urine,  mcreasc  of,  in,  136. 

uterine  contractions  in,  1'27,  131,  135,  462. 

uterine  retraction  in,  138. 

uterine  ligaments  : 
contraction  of,  in,  128. 

uterus,  descent  of,  in,  130. 

vagina,  inliucnce  of,  on,  129,  131. 
Laceration  : 

at  vaginal  orifice,  484,  536,  622,  625. 

in  foot  and  breech  cases,  383. 

of  cervix,  in  labor,  105,  131,  203,  354,  372, 
377,  453,  539,  540,  620. 
treatment  of,  after  labor,  224. 

of  frenulum  in  labor,  134,  622. 

of  genital  canal,  610. 

of  perinaium,  134,   203,  210-214,  224,  249, 
622. 
treatment  of,  after  labor,  224. 

of  uterus,  010,  620. 

of  vagina,  453,  484,  543,  621,  622. 

of  vestibulum,  622. 
Lactation,  240. 

fever  of,  247. 

in  cholera,  264. 

insanity  of,  701,  703. 

of  pregnancy,  94,  701. 
Laminaria  tents,  353. 
Lanugo,  62,  64,  65,  68. 
Laparo-elytrotoniy,  436,  447. 

details  of  operation  for,  449. 

Lffimorrliage,  control  of,  in,  449,  451. 

history  of,  447. 

prognosis  of,  448. 

in  contracted  pelvis,  494. 
Laparotomy  {vide  gastrotomy) : 

in  extra-uterine  pregnancy,  343,  344,  346. 

in  puerperal  peritonitis,  699. 

in  uterine  rupture,  018. 
Lateral  plates,  49. 
Laxatives : 

in  albuminuria,  578. 

in  icterus  neonatorum,  251. 

in  puerperal  fever,  696. 

in  puerperal  state,  254. 
Leeches : 

fecundation  of  ovum  of,  44. 

in  puerperal  fever,  695. 
Length  of  foetus  at  term,  69. 
Levator  ani,  159,  214. 
Liffamenta  lata,  14. 
Ligaments : 

broad,  14. 

contraction  of,  in  labor,  128. 

pelvic,  146. 

pubo-vesical,  161. 

recto-uterine,  15. 

round,  16. 

sacro-sciatic,  147. 


Ligaments: 

uterine,  contraction  of,  in  labor,  128. 

vesico-uterine,  15. 
Ligameritum  : 

arcuatum,  470. 

ovarii,  16. 

teres,  16. 
Ligation,  late,  of  cord,  216  el  seq. 
Linea  alba,  post  partvm,  249. 
Linea  termi/ialis,  144,  151. 
Lip,  anterior  cervical,  obliteration  of,  in  preg- 
nancy, 83,  105. 

uterine  atresia,  by,  540. 
Lips,  development  of,  64. 
Liquor  aninii,  61. 

escape  of,  in  abortion,  320. 
Lithopaidion,  303,  327,  337,  340. 
Liver : 

acute  atrophy  of,  266. 

disease  of,  causing  abortion,  310. 

degeneration  of  fetal,  555. 
Lochia,  241,  245,  249,  252,  255,  684,  689. 

alba,  245. 

inabortio'j,  320,  325. 

in  cholera,  263. 

lactea,  245. 

quantity  of,  245. 

rubra,  245,  255. 

serosa,  245. 
Locking : 

of  children  in  multiple  pregnancies,  234. 

of  forceps,  372. 
Locomotion : 

impeded,  in  labor,  130. 
in  pregnancy,  88. 
Longings  in  pregnancy,  90,  112. 
Lungs,  development  of,  48. 

abortion  from  disease  of,  310,  351,  359. 

capacity  of,  in  pregnancy,  'JO. 
Lusk's  modified  Tarnier  forceps,  378,  379. 
Lutein  cells,  40. 
Lying-in  period : 

duration  of,  255. 
Lymphatics  of  uterus.  28,  77. 

inflammation  of,  in  puerperal  fever,  657. 
679. 

of  pelvis,  in  pregnancy,  29. 

Maceration  : 

of  fattus,  304. 
Magnesia,  for  emesis,  121. 
Malarial  fever  complicating  pregnancy,  122, 
264. 

causing  abortion,  264. 

in  puerperal  state,  653. 
Malformations  (vide  monstrosities) : 

of  child,  556. 
Mamma  : 

acini  of,  in  pregnancy,  87,  247. 


INDEX. 


773 


Mamma : 

anatomy  of,  87,  246. 

areola  of,  88,  90. 
in  pregnancy,  87,  88,  SO,  94,  99,  105. 
in  puerperal  state,  249. 
secondary,  88. 

chancres  of,  in  pregnancy,  87,  88,  90,  94,  99, 
105. 

diseases  of,  706  et  seq. 

in  case  of  fetal  deatb,  1-06. 

lines  on,  in  pregnancy,  88,  105. 

nipple,  ercctility  of,  88. 

secretion  of  milk  in,  246. 

signs  of  pregnancy  relating  to,  87,  88,  90, 
94,  105. 

veins  of,  in  pregnancy,  87,  94,  99. 
Mania  {vide  insanity) : 

etiology  of,  569,  701,  702. 

in  pregnancy,  91,  114. 

prognosis  of,  702. 

puerperal,  701. 

treatment  of,  702. 
Manipulation,  conjoined,  in  pregnancy,  104. 
Marasmus,  in  pregnancy,  114,  118. 
Marc's  cliorion,  villi  of,  55. 
Marginal  insertion  of  cord,  298. 
Marital  relations  in  pregnancy,  113,  116,  317. 
Mastitis,  parenchymatous,  709. 

abscesses  in,  709. 
Maternity  hospitals,  appointments  of,  686. 
Meatus  X(rethrce^  5. 
Meconium,  62,  69,  199,  250,  641. 
Mechanism : 

abnormal,  in  vertex  presentations,  179. 

of  abnormal  face  presentations,  188. 

of  breech  presentations,  199,  487. 

of  breech  presentations,  irregularities   in, 
201. 

of  brow  presentations,  194. 

of  dilatation  of  cervix,  131 

of  face  presentations,  184,  186. 

of  labor,  140,  171. 
effect  of  contracted  pelvis  on,  484,  495. 

of  normal  labor,  171. 

of  occipito-posterior  positions,  179. 

with  monsters,  557. 
Medulla,  development  of,  50. 
Medulla,  of  ovary,  23. 
Medullary  folds,  48,  49. 
Medullary  groove,  49. 
Medullary  tube,  50. 
Melancholia  {vide  insanity) : 
in  pregnancy,  91,  701,  703. 
treatment  of,  702. 
Membrana  granulosa,  37,  38. 
Membrana  propria,  36,  37. 
Membrane,  mucous : 
of  cervix,  19,  81,  95. 
of  ovary,  23,  36. 


Membrane,  mucous: 

of  tubes,  21,  42,  329. 

of  uterus,  18-20,  77,  81,  242. 

of  vagina,  10,  85,  104. 
Membranes  : 

adhesion  of,  455. 

artificial  rupture  of,  in  labor,  208,  580. 

preservation  of,  in  face  presentations,  191. 

retention  of,  in  abortion,  312. 

rupture  of,  in  abortion,  320. 

rupture  of,  to  produce  abortion,  353,  360. 

rupture  of,  in  placenta  previa,  603. 

spontaneous  rupture  of,  132,  140,  208. 
Memory   in    pregnancy,    91,    114,   567,   569, 

701. 
Meningitis  in  puerperal  fever,  669. 
Menses : 

diminution  of,  from  fear,  93. 

suppression  of,  in  pregnancy,  92,  93,  99. 
Menstruation,  39  et  seq. 

last,  as  aid  to  prediction  of  date  of  confine- 
ment, 108. 
Mesenteric  folds,  50. 
Me.«oblast,  47,  48,  49,  50. 
Metritis,  as  result  of  retroflexion  of  gravid 
uterus,  279,  280. 

calomel  in,  464. 

from  retention  of  fojtus,  306,  313. 

in  contracted  pelvis,  492. 

in  labor,  464. 

in  puerperal  fever,  657. 

in  transverse  presentations,  564. 
Micrococci : 

action  of,  on  the  blood,  664. 

in  lochia,  245. 

in  puerperal  fever,  660,  666  et  seq.,  681. 
Micropyle  of  Keber,  43. 
Migration  of  ovum,  41,  51. 

time  required  for,  42. 
Milk,  94,  99,  246. 

absence  of,  in  pregnancy,  94. 

anatomical  considerations  relating  to,  246. 

condensed,  258. 

composition  of,  248. 

fever,  247. 

in  albuminuria,  577. 

in  breasts  of  new-born,  250. 

in  women  not  pregnant,  94. 

-metastases,  661. 

of  one  cow,  257. 

peptonized,  in  emesis,  118,  119. 

of  good  wet-nurse,  256. 

preparation  of,  for  infants,  257,  258, 

secretion  of,  246. 
defective,  706. 

sterilization  of,  258. 

transfusion  of,  590. 

uterine,  55,  56. 
Milk-leg,  70'a;  {vide  phlegmasia  alba  dolens). 


774 


INDEX. 


Miscarriage,  307  (vide  ahortion). 

treatment  of,  326. 
Missed  labor,  304,  305. 
Mola,  312. 

carnosa,  312. 

sanguinea,  312. 
Mole,  hydatidiform,  231,  298. 

anatomy,  morbid,  of,  298. 

diagnosis,  301. 

etiology,  300. 

prognosis,  301. 

symptoms,  301. 

treatment,  302. 
Monstrosities,  556. 

acardiacus,  557. 

acephulus,  658. 

acormus,  559. 

amorphus,  558. 

anencephalus,  559. 

diagnosis  of,  556. 

hemicephalus,  559. 

mechanism  of  labor  with,  557. 

prognosis  in  cases  of,  557. 
Mons  Veneris,  2. 
ilorhus  coxarius,  causing  pelvic  deformities, 

516. 
Morning-sickness  of  pregnancy,  90, 93, 99, 116. 

treatment  of,  116,  118. 
Morsits  dial/oli,  20. 
Morula,  46. 
Morphia  {ride  opium) : 

in  anosmia,  cerebral,  590. 

in  cliorea,  275. 

in  eclampsia,  579. 

in  emesis,  117,  119. 

in  extni-uterine  pregnancy,  345. 

in  neuralgia,  122. 

in  pogt-partum  haemorrhage,  585,  590. 

in  precipitate  labor,  453. 

in  protracted  labor,  457,  462,  502. 

in  puerperal  fever,  695. 

in  shock,  650. 

in  vaginal  thrombus,  628. 
Mouth,  development  of,  48,  63,  64. 
Movements,  fetal,  in  pregnancy,  64,  76,  96, 
98,  99,  100,  106. 

active,  96. 

movements  of  pelvic  joints,  148,  275. 

passive,  96. 

simulation  of,  96. 
Mucous  membrane : 

changes  in,  in  pregnancy,  19,  81,  95. 

of  cervix,  19,  81,  85. 

of  Fallopian  tube,  21,  42,  329. 

of  milk-ducts,  247. 

of  OS,  in  pregnancy,  19,  81,  95. 

of  ovary,  23,  36. 

of  uterus,  body  of,  18,  242. 

of  vagina,  10,  85. 


Mucous  plug,  81. 
Miiller,  ducts  of,  30. 

ring  of,  84,  85. 
Multiparae,  pregnancy  in,  105. 
Multiple  pregnancies,  228. 

acardia  in,  229. 

conduct  of  labor  in,  236. 

development  of  children  in,  229,  231. 

diagnosis  of,  232. 

entrance,   simultaneous,   of  both  children 
into  pelvis,  in,  234. 

fatus  jtapijraceus  in,  231. 

forceps  in,  235. 

frequency  of,  228. 

haemorrhage  in,  236. 

labor  in,  232. 

locking  of  children  in,  234. 

maiKi^rement  of,  228,  236. 

mummification  of  foetus  in,  303,  306. 

origin  of,  228. 

premature  labor,  indicated  by,  351. 

presentations  in,  233. 

prognosis  in,  236. 

treatment  of,  236. 

varieties  of,  228. 

version  in,  236. 

weight  of  children  in,  231. 
Mummification  of  ttetus,  303,  306. 
Muscles : 

action  of  abdominal,  in  labor,  129. 

development  of,  48. 

pelvic,  157. 

recti,  in  pregnancy,  87. 

uterine,  16,  77,  78. 
hyperplasia  of,  77,  78,  124. 
Myomata,  uterine,  542  {vide  uterus,  myoma- 
ta  of;. 

diagnosis  of,  from  pregnancy,  101. 

Naboth,  o^•ula  of,  19,  81. 
Nacgele  oblique  pelvis,  514. 

forceps,  364. 

method  of  computing  date  of  confinement, 
109. 
Nails,  development  of,  4^,  64,  65. 
Narcotics : 

in  ana?mia,  cerebral,  590. 

in  chorea,  275. 

in  eclampsia,  578,  579. 

in  emesis,  117. 

in  lacerations  of  perinseum,  624. 

in  neuralgia,  122. 

in  painful  first  stage,  463. 

in  phlegmasia,  705. 

m  post-part  urn  haemorrhage,  590. 

in  protracted  first  stage,  456. 

in  protracted  third  stage,  462. 

in  puerperal  fever,  695. 

in  puerperal  insanity,  703. 


INDEX. 


775 


N;ite3,  changes  in,  in  pretrnancy,  87,  105. 
Nausea,  of  pregnancy,  90,  93,  99,  116,  117. 

in  eclampsia,  567. 

in  shock,  649. 
Navel : 

changes  of,  in  pregnancy,  87,  100. 

of  new-born  child,  250. 

relation  of  fundus  to,  in  pregnancy,  111. 
Neck,  development  of,  64. 
Negresses,  areola  of,  88. 
Neoplasmata : 

placental,  289. 

uterine  atresia  from,  541,  542,  547. 

vaginal  atresia  from,  538. 
Nephelis  vulgaris : 

fecundation  of  ova  of,  44. 
Nephritis,  indicating  abortion,  351. 

in  eclampsia,  571. 

in  pregnancy,  272. 
Nerve  exhaustion  and  shock,  648. 

etiology,  648. 

treatment,  650. 
Nerves  of  uterus,  27,  77. 
Nervous  system : 

development  of,  48,  50. 

diseases  of,  in  pregnancy,  88,  91,  114,  122. 
Neuralgia  in  pregnancy,  88,  91,  114,  122. 
New  formations  in  placenta,  289. 
Newly  bom  child,  250  (  vide  infant). 

asphyxia  of,  215,  368,  635. 

breasts  of,  250. 

caput  succedaneum  of,  181,  190,  250. 

cardiac  ventricle  of,  250. 

care  of,  250,  356. 

circulation  of,  216.  250. 

desquamation  of,  250. 

ductus  (wteriosus  of,  250. 

fteces  of,  251. 

foramen  ovale  of,  250. 

icterus  of,  219,  250. 

milk  prepared  for,  257,  258. 

navel  of,  250. 

nurse  for,  selection  of,  256. 

nursing  of,  254. 

ophthahnia  of,  712. 

size  of,  69. 

urine  of,  250. 

weight  of,  69,  251. 
Nipples  : 

changes  in,  during  pregnancy,  88,  90   94. 

cracked,  708. 

erectility  of,  88 

erosions  of,  707,  708. 

fissured,  707. 

sore,  255,  706. 
shields  for,  255,  708. 
treatment  of,  707- 
Nose,  development  of,  48,  64. 
Notches,  sacro-sciatic,  145. 


Nucleus,  vitelline,  45. 
Nurse,  wet,  selection  of,  256. 
Nursing : 

contra-indications  for,  254. 

in  pregnancy,  254. 

intervals  for,  254. 
Nutrition  in  pregnancy,  89,  90,  91. 
Nux  vomica  in  nausea  of  pregnancy,  117. 
Nyctalopia  : 

in  pregnancy,  91. 

in  puerperal  state,  568. 
Nymphffi,  3  {vide  Labia  minora). 

sebaceous  glands  of,  5. 
Nymphomania,  702. 

Obliquity,  lateral,  of  Nsegele,  170, 
Obstructed  labor,  due  to — 

abdominal  tumors  of  foetus,  554. 

abnormaties    of    foetus,   551    et    seq.   {lids 
foetus). 

aeardiacus,  557. 

anchylosis  of  fetal  joints,  556. 

arm,  extended,  394. 

ascites,  fetal,  554. 

atresia,  uterine,  539  {vide  atresia). 

atresia,  vaginal,  536. 

atresia,  vulvar,  535. 

bladder,  distended,  554. 

calculi,  537. 

coiling  of  cord,  204,  215,  296. 

cystoccle,  555. 

displacements,  uterine,  116,  278  et  seq.,  310. 

ectopia  of  abdominal  organs,  556. 

encephalocele,  congenital,  553. 

faeces,  impacted,  208. 

fatty  growths,  555. 

fibrous  growths,  538. 

hernias,  vaginal,  538. 

hernias,  visceral,  556. 

hydrocephalus,  fetal.  551. 

hydrothorax,  fetal,  554. 

hymen,  persistent,  535. 

hypertrophy  of  cervix,  282,  542. 

knots  of  cord,  295. 

locked  twins,  234. 

monstrosities,  556. 

morbid  growths  of  genital  canal,  535  et  seq. 

multiple  pregnancy,  234. 

ossification  of  fontanelles,  premature,  551. 

ovarian  tumors,  548. 

perineum,  rigid,  368,  459,  536. 

rigor  mortis,  fetal,  556. 

short  cord,  559. 

spina  bifida,  556. 

transverse  presentations,  560. 

tumors,  intrapelvic,  533,  542. 
Obturator  foramen,  159. 
Occipito-postcrior  positions : 

forceps  in,  379. 


776 


INDEX. 


Occipito-posterior  positions: 

mechanism  of,  179. 

rotation  in,  175. 
Odontali^ia  in  pregnancy,  91. 
Oidema : 

cerebral,  in  eclampi^ia,  675. 

cervical,  in  labor,  540. 

indicating  abortion,  351. 

in  eclampsia,  567,  577. 

in  labor,  130,  308,  620. 

in  maceration  of  fojtus,  304. 

in  pregnancy,  8S,  114,  115,  130, '268,  273, 
279,  549,  567. 

placental,  288. 

vulvar,  in  labor,  130,  636. 

vulvar,  in  pregnancy,  88,  114,  273,  279. 
Oophoritis,  in  puerperal  fever,  668. 
Oosperm,  45. 
Operation : 

tor  Cte.sarean  section,  439. 

for  causing  premature  labor,  351.  360. 

for  cephalotripsy,  4'25. 

for  embryotomy,  413,  431. 

for  extraction  of  foetus  in  breech  presonta^ 
tions,  382  et  seq. 

for  lacerated  nerinajum,  623. 

for  perforation  in  craniotomy,  414,  428. 

for  producing  abortion,  351. 

Torro's,  or  ovaro-hystorectomy,  442. 
details  of,  443. 

Fehling's  modification  of,  444. 
history  of,  442. 

Thomas's,  or  laparo-elytrotomy,  436,  442. 
details  of,  449. 

ha^morrhaije,  control  of,  in,  449,  451. 
history  of,  447. 
proffnosis  of,  448. 
Ophthalmia  neonatorum,  prophylaxis  of.  712. 
Opiates : 

in  abortion,  318,  323. 

in  anajraia,  cerebral,  590. 

in  chorea,  275. 

in  eclampsia,  579,  531. 

in  emesis,  117,  119. 

in  insomnia,  122. 

in  lacerated  pcrinanim,  624u 

in  mastitis,  710. 

in  neuralgia,  122. 

in  painful  first  stage,  463. 

in  peritonitis,  464. 

in  phlegmasia  alba  dolens,  705. 

in  post-part)im  hnemorrhage,  585,  590,  591. 

in  precipitate  l.ibor,  453. 

in  protracted  labor,  457,  462. 

in  puerperal  fever,  695. 

in  puerperal  state,  252. 

in  shock,  650. 

in  vaginal  thrombus,  628. 
Opisthotonus,  in  eclampsia,  568. 


Organs  of  generation  : 

abnormities  of,  635. 

anatomy  of  female,  1. 

changes  in,  during  pregnancy,  77  ct  seq. 

development  of,  29. 

external,  1. 
Orifice,  oral,  development  of,  48,  63,  64. 
Orijicium  ■vaf/iiue,  6,  7. 
Os  innominatum,  anatomy  of,  142. 
Osteomalacia : 

pelvic  deformity  from,  529  (»i(/«;  pelvis,  de- 
formed, osteomalacic). 

pseudo-,  478,  533. 
Osteophytes  in  pregnancy,  S9. 
Os  tincce,  12. 

internum,  13. 

closure  of,  during  pregnancy,  82,  85. 
Os  uteri : 

changes  of,  in  pregnancy,  80-S6,  95,  105. 
in  puerperal  state,  243. 

dilatation  of,  in  labor,  131,  137. 
causes  of,  137. 
in  emesis,  119. 

elongation  of  anterior  lip  of,  in  labor,  540. 

erosions  on,  during  pregnancy,  81,  243. 

mucous  membrane  of,  19,  81,  95. 

oedema  of  anterior  lip  of,  in  labor,  540. 

rigidity  of,  atresia  from,  540. 

thrombus  of,  in  labor,  540. 
Ova,  number  of,  41. 

primordial,  36,  38. 
Ovarian : 

cysts,  diagnosis  of,  from  pregnancy,  101, 
550. 

pregnancy,  327.  3-34,  338. 

tuuiors,  diagnosis  of,  549. 

tumors,  obstructing  labor,  548. 
Ovaries : 

anatomy  of,  21. 

arteries  of.  25. 

cortical  substance  of,  23. 

development  of,  30. 

diseharice  of  ovum  from.  39. 

epithelium,  cylindrical  ciliated,  in,  23,  36. 

erectility,  theoretical,  of,  27. 

follicles  of.  23,  36-39. 

hilum  of,  22. 

ligament  of,  16,  21. 

medullary  .substance  of,  23. 

poritonreum,  relations  of,  to,  22. 

Porro's  operation  to  remove,  442. 

position  of,  in  pregnancy,  79. 

relation  to  Wolffian  bodies,  30. 

tumors  of,  in  pregnancy  and  the  puerperal 
state,  548. 
diagnosis  of,  549. 

tunica  (tlhvgitiea  of,  23. 

veins  of,  26. 
Ovariotomy,  in  pregnancy,  550. 


INDEX. 


Ovaritis,  puerperal,  G63. 
O»aro-hi/storectomij,  442. 

details  of,  443. 

Fehling's  method  in,  444. 

Frank's  method,  445. 

Iiistory  of,  442. 
Ovulaof  Naboth,  19,  81. 
Ovulation,  39. 

iruppression  of,  in  prcirnancy,  93. 
Ovum  : 

abdominal  plates  of,  49. 

amnion  of,  50. 

anatomy  of,  38,  62. 

area  germinatira  of.  47,  50. 

embryonic,  47,  48,  52. 

blastodermic  vesicle  of,  47,  50. 

changes  in,  subsequent  to  fucuudatioa,  44. 

chorda  dorsalis  of,  49. 

chorion  of,  51,  53,  G4. 

cleavage  of,  46. 

deutoplasm  of,  39,  45. 

development  of,  35,  62. 

discharge  of,  from  ovary,  39. 

discus proligerus  of,  37,  3S,  39. 

diseases  of,  284. 

dorsal  plates  of,  49,  62. 

embryonic  area  of,  47,  62. 

epiblast  of,  47,  48. 

epithelium,  cylindrical  ciliated,  in,  37. 

fecundation  of,  42^4. 

-forceps,  in  abortion,  324. 

germiuative  spot  of,  39. 

germinative  vesicle  of,  39,  45. 
disappearance  of,  45. 

hypoblast  of,  47,  4S. 

membrana  granulosa  of,  37,  38. 

mesoblast  of,  47,  48. 

micropyle  in,  43. 

migration  of,  41,  51,  328. 

morula  of,  46. 

polar  globule  of,  45. 

premature   expulsion   of,    307  {vila  labor, 
premature). 

primitive  trace  of,  48. 

primordial,  30,  38,  39. 

pronucleus  of,  45. 

removal  of  retained,  321. 

segmentation  of,  46. 

size  of,  38. 

time  for  migration  of,  42. 

tubus  medullaris  of,  50. 

umbilical  vesicle  of,  50. 

vitelline  membrane  of,  38. 

vitellus  of,  39. 

yolk  of,  39. 

zona  pellucida  of,  38. 
Ovum-forceps : 

use  of,  in  abortion,  324. 
Oxygen,  in  nausea  of  pregnancy,  117. 


Oxytocics : 

after  normal  labor,  224. 

contra-indications  for,  461. 

in  abortion,  320,  321,  323,  351. 

indications  for,  224,  460. 

in  parturition,  224,  461. 

in  placenta  prsevia,  603,  606. 

in  post-partum  hsemorriiage,  585. 

in  protracted  first  stage  of  labor,  457,  458. 

physiological  action  of,  460. 

Pack,  wet,  in  puerperal  fever,  698. 

in  albuminuria,  578. 
Pad,  antiseptic,  225,  253,  688,  691. 
Pains : 

action  of,  on  uterine  walls,  128. 

after-,  224,  244,  252,  672. 

anomalies  of,  452. 

causes  of,  130. 

character  of,  129,  130,  452,  454. 

contracted  pelvis,  ali'ecting,  481. 

duration  of,  128. 

effect  of  chloroform  on,  227. 

efi'ect  of,  on  fetal  heart,  97. 

good,  452,  454,  4b2. 

in  abdominal  walls,  during  pregnancy,  87. 

in  abortion,  311. 

in  breasts  during  pregnancy,  87,  94,  99. 

in  first  stage,  131. 

in  second  stage,  133. 

irregular,  in  first  stage,  454. 

irregular,  in  second  stage,  459. 

ii  regular,  in  third  stage,  461. 

labor-,  127,  129,  452,  454,  4S2. 

influence  of  coriti'acted  pelvis  on,  479. 
influence  of,  on  organism,  130. 

premonitory,  131. 

seat  of,  130. 

strong,  452. 

weak,  452. 
forceps  for,  368. 
Palate,  development  of,  64. 
Palpation,  abdominal,  in  pregnancy,  100. 

vaginal,  99,  103. 
Palpitation  of  heart  in  pregnancy,  114,  292. 
Pancreas : 

dilatation  of  fetal,  555. 
Papillae,  vaginal,  hypertrophy  of,  in  pregnan- 
cy, 86,  105. 
Paqueliu's  thermo-cautery,  in  Thomas's  op- 
eration, 450. 
Parametritis  from  retroflexed  gravid  uterus, 
280. 

in  contracted  pelvis,  492. 

in  puerperal  fever,  657,  658,  672. 
Paresis  in  pregnancy,  91. 
Parturition,  123  [vide  labor). 
Patches,  brown,  in  pregnancy,  91. 
Pathology  of  labor,  452. 


m 


INDEX. 


Pathology  of  pregnancy,  260. 

Pelvic  abscess,  674,  700. 

Pelvic  brim,  151,  154,  157,  169  {i)ide  brim, 

pelvic). 
Pelvic  cavity,  general  direction  of,  151,  153. 
Pelvic  cellulitis,  in  puerperal  lever,  658. 
Pelvic  measurement,  407. 
external,  467. 
instruments  for,  467. 
iriternal,  469. 

of  conjugata  vera,  151,  469,  470. 
of  diagonal  conjugate,  469,  470. 
of  external  conjugate,  469. 
of  transverse  diameter,  471. 
Pelvic  peritonitis  in  puerperal  lever,  659,  668, 

672. 
Pelvic  walls,  lengtli  of,  150. 
Pelvimeter,  407. 
circle  of  Baudelocque,  407. 
Schultze's,  407. 

the  hand  as,  for  internal  measurements,  469. 
Pelvimetry  : 
external,  468. 
instruments  for,  407. 
internal,  469. 
Pelvis : 
abscess  in,  674,  700. 
adult,  causes  of  its  conformation,  155. 
aquaMliter  justo-minor^  465,  471,  485,  495, 
512. 
diagnosis  of,  472. 
agents  shaping  the  adult,  155. 
anatomy  of,  140  et  seq.,  154. 
arteries  of,  158. 
articulations  of,  145. 
mobility  in,  148,  275. 
rupture  ot,  628. 
as  a  whole,  149. 
axes  of,  150,  152,  153. 
brim  of,  151,  154,  157,  169. 

inclination  of  plane  of,  147. 
cavity  or  canal  of,  151,  153. 
conjugate  of,  151,  469,  470. 
contracted,  465. 

as  indication  for  abortion,  349,  359. 
Ctesarean  section  in,  438. 
diagnosis  of,  466. 
from  history,  466. 
from  measurements,  467. 
effects  in,  of  pressure  on  mother,  488. 
effects  in,  of  pressure  on  child,  489. 
effects  of,  on  labor,  479. 
extravasations,  intra-cranial,  in,  491,  498, 

506. 
fascia  of,  161,  162. 
forms  of,  three  principal,  471. 
fractures  in,  491. 
frequency  of,  466. 
generally,  477. 


Pelvis,  contracted  : 

influence  of,  in  pregnancy  and  labor,  479. 
on  cranial  bones,  490. 
on  first  stage,  483. 
on  labor-pains,  481. 
on  mechanism  of  labor,  484  et  seq. 
on  position  of  foetus,  485,  486. 
on  presentations  of  foetus,  480,  481. 
on  uterus  in  pregnancy,  480,  612. 
irregularly : 
pseudo- osteomalacia,  478,  533. 
kyphosis,  479. 
rachitis,  478. 
scoliosis,  479. 
labor,  at  term,  in,  502. 
pi-ognosis  in,  492. 
scalp-tumor  in,  483,  439. 
symmetrically,  471,  474. 
treatment  in,  486,  493. 

by   CiBsarean   section,   494,   499.    513, 

518,  521,  524,  5ii8,  533. 
by  craniotomy,  494,  499,  510,  513,  519, 

521. 
by  forceps,  497,  503,  508,  511. 
by  laparo-elytrotomy,  494. 
by  premature  labor,  500. 
by  version,  498,  499,  503  et  seq. 
expectant,  509. 

when    child    can    not    be    delivered 

through  natural  passages  alive,  494. 

when  child  may  be  delivered  through 

natural  passages  alive,  500. 
when  craniotomy  or  abortion  must  be 
performed,  497. 
varieties  of,  465. 
deformed,  rare  forms  of,  514. 
deformed  by — 
absence  of  symphysis,  534. 
exostosis,  533. 
fractures,  533. 
morbus  coxae,  516. 
osteomalacia,  529. 
rachitis,  475,  478. 
diameters  of,  150  et  seq.,  157,  169. 
difference  between — 
adult  and  infantile,  155. 
female  and  male,  154. 
exostosis  of,  533. 
exudations  in,  treatment  of,  700. 
fascia  of,  161,  162. 
female,  154,  156. 
flattened,  465,  469,  474,  512. 
general,  465,  477,  512. 
mechanism  of  labor,  in,  484  et  seq. 
non-rachitic,  474. 
rachitic,  475. 
diagnosis  of,  477. 
irregular,  478. 
simple,  465,  512. 


INDEX. 


19 


Pelvis: 
floor  of,  159,  ICO. 
forceps  at  brim  of,  375. 

at  outlet  of,  368. 
funnel-shaped,  528. 
inclination  of,  147. 
inclined  planes  of,  153. 
justo-niinor,  4G5,  471,485.  495,  512. 
kyphotic,  479,,  519. 

treatment  of,  521. 
large,  the,  149. 
ligaments  of,  146. 
lymphatics  of,  iu  preirnaney,  29. 
male,  154. 

measurements  of,  467,  469. 
movements  in  joiiits  of,  148,  275. 
muscles  of,  157  ei  seq. 
Naegele's  oblique,  514  {vide  obliqu'.). 
nana,  472. 
osteomalacic,  529. 

anatomy,  morbid,  of,  530. 

diagnosis  of,  532. 

etiology  of,  531. 

prognosis  of,  532. 

treatment  of,  532. 
oblique,  of  Naegelc,  514. 

anatomy,  morbid,  of,  514. 

diagnosis  of,  517. 

etiology  of,  516. 

mechanism  of  labor  in,  517. 

prognosis  in,  518. 

treatment  in,  518. 
outlet  of,  152,  159. 
outlet  of,  forceps  at,  368. 
planes  of,  150. 

inclined,  153. 
pressure  of  contracted,  on  cranium,  490. 
pseudo-osteonialaeic,  478,  533. 
rachitic,  475,  478. 
rela.xution  of  symphysis  of,  in  pregnancy, 

275. 
Eobert's  anchylosed  and  transversely  con- 
tracted, 523. 

anatomy,  morbid,  523. 

diagnosis,  524. 

etiology,  524. 

prognosis,  524. 
scoliotic,  479. 
scolio-rachitic,  521. 
small,  the,  150. 
soft  parts  of,  157. 
spondolisthetic,  525. 

anatomy,  morbid,  525. 

diagnosis,  526. 

etiology,  526. 

prognosis,  527. 
straits  of,  151,  152. 
symphysis  of,  relaxation  iu,  275,  628. 

absence  of,  534. 


Pelvis : 

tumors  of,  indicating  abortion,  359,  533. 

veins  of,  158. 

walls  of,  their  length,  150. 
Penis,  development  of,  64. 
Pepsin,  in  nausea  of  pregnancy,  117. 
Perforation,  413. 

extraction  of  child  after,  419. 
by  forceps,  419. 
by  cephalotribe,  420. 

indications  for,  413,  497,  617. 

in  face  presentations,  418. 

instruments  for,  414  (vide  perforators). 

of  after-coming  head,  418. 

of  uterus,  from  pressure,  610. 

operation,  how  perfoimed,  414. 

point  I'or,  418. 

preparations  for,  414. 
Perforator,  414. 

Blot's,  415. 

Hodge's  cranial  scissors,  415. 

Simpson's,  414,  415. 

Smellie's  scissors,  414. 

Thomas's,  416. 

trephine,  416,  419. 
Pericarditis,  in  puerperal  fever,  680. 

fetal,  obstructing  labor,  554. 
Perimetritis,  in  contracted  pelvis,  492. 

in  retention  of  Itetus,  313. 

in  puerperal  fever,  672. 
Pcrinseum  : 

body  of,  162,  164. 

connective  tissue  of,  164. 

dilatation  of,  in  labor,  134. 

fascia  of,  161. 

gangrene  of,  536. 

in  labor,  134. 

laceration  of,  in  labor,   134,  203,  211,  224, 
453,  622. 

muscles  of,  162,  164,  214. 

preservation  of,  in  labor,  193,  210  et  seq. 

rigidity    of,  obstructhig    labor,    368,   459, 
536. 

thrombus  of,  625. 

treatment  of  lacerated,  224,  623. 
in  labor,  224. 

in  pueqieral  state,  224,  249. 
Period,  lying-in,  duration  of,  255. 

placental,  of  labor,  134. 
Peritoneum,  relations  of,  to  ovaries,  22. 
Peritonitis,  as  result  of  incarceration  of  retro- 
fle.xed  gravid  uterus,  280. 

after  labor,  464,  492,  564. 

in  abortion,  313,  325,  355. 

in  atresia,  541. 

in  extra-uterine  pregnancy,  339,  340. 

in  ovarian  tumors,  549. 

in  puerperal  fever,  659,  668,  672,  677,  680. 

in  retained  foetus,  306,  313. 


780 


INDEX. 


Pessary,  in  retroversion  and  retroflexion  of 

gravid  uterus,  llfi,  278,  317. 
Phantom  tumors,    difterentiation    of,    from 

pregnancy,  102. 
Phlebitis  and  phlebo-thromLosis  in  puerperal 

fever,  660,  680. 
Phlebotomy  in  eclampsia,  579,  581. 
phlegmasia  alba  dolens^  646,  701,  704. 
abscesses  in,  705. 
etiology,  704. 
history,  clinical,  of,  705. 
origin  of,  704. 
prognosis  of,  705. 
treatment  of,  705. 
Phthisis  complicating  pregnancy,  270. 

abortion  in,  270. 
Physician,    visits   of,   during   the   puerperal 

stale,  252. 
Piles,  in  pregnancy,  88,  115. 
Pilocarpine,  in  salivation,  121. 
Pinces  Muiostatiques,  622. 
Placenta : 

adherent,  221,  462,  593. 
anatomy  of,  51,  54. 
anomalies  of,  287. 
in  circulation,  288. 
in  development,  288 
in  foiTa,  287. 
in  position,  288. 
apoplexy  of,  288. 
arteries  of,  58,  50. 
artificial  separation  ot,  593,  604. 
hattledoor,  298. 
bruit  of,  24,  98. 

calcireous  degeneration  of,  289. 
cotyledons  of,  56,  59. 

arteries  of,  59. 
cystic  degeneration  of,  289,  299. 
degenerations  of,  289,  317,  351. 

in  cholera,  263. 
development  of,  54,  64. 
expression   of,    by    Credo's    method,    220, 
324,  462. 
in  tardy  labor,  463. 
expulsion  of,  physiology  of,  221. 
fatty  degeneration  of,  289,  351. 
fetalis^  56. 
fully  developed,  58. 
functions  of,  59. 
in  abortion,  324,  325. 
in  Caesarean  section,  440. 
infarctions  of,  288. 
inflammation  of,  289,  290,  304. 
in  multiple  pregnancy,  232. 
membranacea,  288. 
new  growths  in,  289. 
normally   implanted    haemorrhages    from, 

606. 
aedema  of  288. 


Placenta : 
prrevia,  594. 

abortion  in,  597,  600. 
accouchement  force  in,  G02,  603. 
anaemia  in,  598. 
cervix  in,  600. 
clinical  features  of,  596. 
diagnosis  of,  599. 
dilator,  Barnes's  in,  602  et  seq. 
douche  in,  606. 
ergot  in,  603,  606. 
etiology  of,  596. 
foitalts,  56. 
forceps  in,  375,  603. 
frequency  of,  595. 
hemorrhages  in,  597,  599,  601,  605. 
history,  clinical,  of,  596. 
indicating  abortion,  351. 
presentations,  abnormal,  in,  598. 
prognosis  of,  599,  600,  605. 
pyaemia  in,  599. 
situation  of,  594. 
tampon  in,  601. 
thrombi  in,  238,  249,  599. 
treatment  of,  600,  601. 
by  Barnes's  dilator,  602,  604. 
by  detachment  of  placenta,  604. 
by  ergot,  603.  606. 
by  forceps,  603. 
by  tampon,  601,  604. 
by  version,  602,  603. 
varieties  of,  595. 
retained,  221,  461,  462,  581,  584,  586,  592. 
in  abortion,  312,  325. 
prevention  of.  221,  463. 
treatment  of,  325,  351,  463,  593. 
site  of,  posf-partum,  242,  249. 
spuria,  288. 

structure  of,  fully  developed,  58. 
svcce/ituriata,  288,  586. 
syphilis  of,  272,  290. 
tlirombosis  of  sinuses  of,  288. 
tumors  in,  2b9. 
uterina,  57. 
vascular  spaces  of,  57. 
villi  of,  54-57,  290. 
in  cat,  56. 
in  marc,  55. 
Placentitis :  289,  290,  304. 

abortion  in,  289,  304. 
Planes  of  pelvis,  150,  153. 
Plates : 
abdominal,  49. 
dorsal,  49,  62. 
lateral,  49. 
Plethora  of  pregnancy,  88. 
PleurL^y,   chronic,  complicating   pregnancy, 

270. 
Pleuritis,  in  puerperal  fever,  669,  680. 


INDEX. 


781 


Pleurosthotonus,  in  eclampsia,  568. 
Plexus : 
hypoijaBtric,  27. 
painpinitbrmis,  25. 
uterinus,  25. 
niagnus,  27. 
J'licce. : 

reeto-zderincB,  15. 
vesico-tderinix,  15. 
Plu!?,  mucous,  of  cervix,  81 . 
Plural  prcffnaucy,  228  i^vide  pregnancy,  mul- 
tiple). 
Pneumonia,  acute  lobar,  complicating  preg- 
nancy, 269,  35!). 
Podalic  version,  401,  40i. 
Polar  globule,  45. 

Polypus,  fibrinous,  removal  of,  326. 
causing  puerperal  luemorrhages,  592. 
in  abortion,  313. 
simulating  menses,  93. 
vulvar,  536. 
Porro's  operation,  442  (ride  ovaro-hystorec- 
tomy). 
details  of,  443. 

Fehling's  modification  of,  444. 
Frank's  modification  of,  445. 
history  of,  442. 
in  uterine  tumors,  545,  548. 
Porte-fillet,  392. 
Portio  vaginalis  of  cervix,  12. 

lacerations  of,  620. 
Positions : 
changes  of,  76. 
classification  of,  170. 
definition  of,  76. 
diagnosis  of,  183. 
first,  76. 

fore.xamination,  in  pregnancy,  99. 
forceps,  use  of,  in  occipito-posterior,  379. 
in  breech  presentations,  197. 
in  contracted  pelvis,  486. 
in  multiparEe,  75. 
in  primiparEe,  75. 
mento-posterior,  forceps  in,  381. 
oblique,  as  cause  of  face  presentations,  184. 
occipito-anterior,  170. 
occipito-posterior,  170,  179. 
forceps  m,  379. 
lacerations  in,  214. 
mechanism  of,  179. 
rotation  in,  175. 
transverse,  forceps  in,  381. 
second,  76. 
Post-partum  htemorrhage,  581  (vide  hsemor- 

rhage,  pod-partum). 
Posture : 

in  first  stage  of  labor,  208. 
in  second  stage  of  labor,  209,  210. 
Praputium  clitoridis,  4. 


Prague  method   of  extraction  with  head  at 

the  brim,  399. 
Precipitate  labor,  453  (^vide   labor,  precipi- 
tate). 
Pregnancy : 
abdomen  in,  86,  94,  99, 100,  105,  278. 
abdominal,  42,  327,  335,  339. 
collapse  in,  338. 
definition  of,  327. 
diagnosis  of,  280,  340. 
electricity  in,  345. 
clytrotomy  in,  346. 
haemorrhage  in,  327,  346. 
injections  into  sac  in,  345. 
interstitial,  332. 
mtraligamentous,  331. 
laparotomy  in,  343,  344,  346. 
ovarian,  327,  328,  338. 
peritonitis  in,  339,  340. 
puncture  of  sac  in,  345. 
recurrence  of,  328. 
secondary,  339. 
septiciemia  in,  340. 
symjitoms  of,  338. 
terminations  of,  327,  333,  339. 
treatment,  343. 

of  advanced  cases,  346. 

of  cases  prolonged  after  death   of  fos  - 

tus,  348. 
of  early  cases,  343. 
tubal,  327,  328. 
tubo-abdominal,  338. 
tubo-ovarian,  338. 
acardia  in  multiple,  229. 
accidental  complications  of,  260. 
air,  fresh,  in.  112. 
albuminuria  in,  91,  262,  268,  273,  275,  567, 

569,  577. 
alimentation,  rectal,  in,  119. 
amaurosis  in,  91. 
amblyopia  in,  91. 
amenorrhoea  in,  92,  93. 
amniotic  fluid  obscuring,  95. 
anaemia  in,  114,  122. 
angesthesia  in,  91,  102. 
anodynes  in,  117,  119. 
anorexia  in,  114. 
anteflexion  in,  116,  278. 
anteversion  in,  80,  278. 
appetite  in,  90,  114. 
areola  in,  88,  90,  94.  99,  240, 
ascites,  in,  102. 
auscultation  in,  96,  102,  106. 
auscultatory  signs  of,  96,  102,  106. 
ballottement  in,  96,  101,  104. 
bladder  and  rectum,  functional  disease  '•'t'. 

in,  88. 
blood-changes  of.  88,  113,  115. 
bowels  in,  90,  118. 


782 


INDEX. 


Pregnancy : 

breasts  in,  87,  88,  90,  94,  99,  105,  106. 

brown  patches  in,  91. 

bruit,  uterine,  in,  96,  98,  103. 

cancer  of  cervix  in,  546. 

carbonic  dioxide,  increase  of,  in,  89. 

cardiac  diseases  in,  89,  266. 

carunculas  in,  105. 

cathartics  in,  115. 

ceplmlalgia  in,  122. 

cervical,  309,  596. 

changes,  in  abdominal  walls  in,  87. 

in  blood  in,  88,  113,  115. 

in  breasts  in,  87,  88,  90,  94,  99,  105,  106. 

in  cervix  uteri  in,  80-86,  95, 105,  116. 

in  entire  organism  in,  88. 

in  heart  in,  89. 

in  hips  in,  86. 

in  nates  in,  87,  105. 

in  navel  in,  87,  100. 

in  nipple  in,  88,  90,  94. 

in  OS  uteri  in,  80-86,  95,  105. 

in  sexual  apparatus  and  neighboring  or- 
gans in,  77,  105. 

in  thighs  in,  87. 

in  thyroid  in,  89. 

in  umbilicus  in,  87. 

in  uterus  in,  77,  105. 

in  vagina  in,  85,  105. 

in  vulva  in,  86,  105. 

in  walls,  abdominal,  in,  87,  100,  105. 
character  in,  91. 
cholera  complicating,  263. 
chorea  complicating,  114,  274. 
circulation,  disorders  of,  in,  114,  115. 
coiling  of  cord  complicating,  296. 
coitus  in,  113,  116. 
complicated  by : 

albuminuria,  91,  262,  268,  273,  275,  567, 
569,  577. 

amaurosis,  91. 

amblyopia,  91. 

anaemia,  114. 

anaesthesia.  91. 

anomalies  of  cord,  293. 

anomalies  of  placenta,  287. 

anteflexion  and  anteversion,  80,  116,  278. 

ascites,  95. 

calcareous  degeneration  of  cord,  298. 

cardiac  diseases,  89,  266,  310,  351,  359. 

cephalalgia,  122. 

cholera,  263. 

chorea,  114,  274. 

circulatory  disorders,  114,  115. 

coiling  of  cord,  296. 

constipation,  88,  90,  116,  118,  122. 

conti-acted  pelvis,  479  et  seq. 

cramps,  88. 

cysts  in  cord,  297. 


Pregnancy,  complicated  by : 
deafness,  91. 
death  of  foetus,  106. 
deficiency  of  amniotic  fluid,  293. 
delirium,  118. 
diabetes,  274. 
diarrhoea,  90,  118. 
dizziness,  91. 
dropsy,  114. 

dyspnoea,  90,  114,  292,  351,  549,  567. 
eclampsia,  567. 
eme.sis,  93,  99,  116,  117. 
emphysema,  270. 
empyema,  270. 
endometritis,  272,  284-286. 
exanthemata,  260. 
face-ache,  91,  122. 
flatulence,  112. 
gangrene,  115. 
goitre,  89. 
headache,  122. 
heartburn,  112,  121. 
heart-disease,  89. 
hernias  of  cord,  296. 
hernias  of  uterus,  283. 
hydatidifonii  mole,  293. 
hydremia,  89,  115. 
hydramnion,  95,  103,  290. 
hyperosmia.  118. 
hypertrophy  of  heart,  89. 
hysteria,  114. 
icterus,  266. 

incontinence  of  urine,  88.  278. 
indigestion,  88,  90,  114,  118. 
insanity,  91,  114,  701. 
insomnia,  122. 
knots  in  cord,  295. 
locomotion,  impaired,  88. 
maceration  of  foetus,  304. 
malarial  fever,  122,  264. 
mania,  91,  114. 
measles,  261. 
missed  labor,  304,  305. 
mummification  of  foetus,  303,  306. 
nausea,  90,  93,  99,  116,  117. 
nephritis,  chronic,  272. 
neuralgia,  88,  91,  114,  122. 
oedema,  88,  114,  115,  130,  268. 
osteophytes,  89. 
palpitation,  114. 
paresis,  91. 
phthisis,  270. 
placentitis,  289,  290. 
plethora,  88. 
pleurisy,  chronic,  270. 
pneumonia,  269. 
prolapse  of  uterus,  282. 
prolapse  of  vagina,  283. 
pruritus,  91,  121. 


INDEX. 


783 


Pregnancy,  complicated  by : 

relapsing  fever,  264. 

retention  of  dead  fostus,  302. 

retroflexion,  279. 

retroversion,  279, 

rubeola,  261. 

salivation,  90,  94,  US,  121. 

scarlatina,  262. 

stenosis  of  umbilical  vessels,  297. 

syncope,  91,  114,  118. 

syphilis,  271. 

taste,  perversions  of,  91,  118. 

torsion  of  cord,  293,  303. 

tumors,  ovarian,  548. 

tumors,  uterine,  542,  546. 

typhoid  fever,  264. 

typhus  fever,  264. 

varicose  veins,  88,  115. 
variola,  261. 
vertigo,  91,  114,  118. 
vomiting,  90,  93,  99,  116,  117,  359. 
complications  of,  accidental,  260. 
constipation  in,  88,  90,  116,  118, 122. 
contractions  of  uterus  in,  lOlj  131. 
cravings  in,  91,  118. 
deafness  in,  91. 
delirium  in,  118. 
diabetes  in,  274. 
diagnosis  of,  91. 
diagnosis  of  dead  foetus  in,  106. 
diagnosis,  differential  of,  101  et  seq. 
diagnosis  of  multiple,  232. 
diarrhoea  in,  90. 
diet  in,  112,  114,  117. 
digestion  in,  90,  93,  114,  116,  464. 
discoloration  of  skin  in,  91. 
disorders  of,  113. 

distinction  between  first  and  second,  104. 
dizziness  in,  91,  114,  118. 
dolores  presagientes  in,  131. 
douche,  vaginal,  in,  113. 
dress  in,  113. 

dropsy  in,  88,  114,  115,  130,  279,  567. 
dropsy  of  amnion  in,  95,  103. 
duration  of,  62,  106,  123. 
dyspnceain,  90,  114. 
eclampsia  in,  567. 

effects  of,  on  nervous  system,  91,  114,  122 

electricity  in,  117. 

emesis  in,  93,  99,  116  ef  seq.,  280. 

emphysema  complicating,  270. 

empyema  complicating,  270. 

endometritis  during,  272,  284. 

ergotin  in,  116. 

exanthemata  in,  260. 

exercise  in,  113,  122. 

exploration,  methods  of  physical,  99. 

extra-uterine,  280,  327. 

face-ache  in,  91,  122. 


Pregnancy : 
fetal  heart-sounds  in,  96,  97,101,  10  3,  106. 
flatulence  in,  112. 
foetus,  death  of,  in,  106. 
frenulum  in,  105. 
frequency  of  multiple,  228. 
funic  souffle  in,  98. 
gangrene  in,  115. 
haemoglobin  in,  89. 
hfemorrhoids  in,  88,  115,  130. 
heart-burn  in,  112,  121. 
heart,  hypertrophy  of,  in,  89. 
heart-sounds,  fetal,  in,  96,  97,  101, 103. 106. 
hernia,  of  cord  in,  296. 

of  uterus  in,  283. 
hips  in,  86. 
hydraeniia  in,  89,  115. 
hvdrsemic  oedema  in,  88, 114,  115,  130,  279. 
hydramnion  in,  95,  103,  290. 
hygiene  of,  112. 
hymen  in,  105. 
hyperosmia  in,  118. 
hysteria  in,  114. 
ice,  use  of,  in,  117, 119. 
icterus  complicating,  266. 
impaired  digestion  in,  88,  90,  114. 
incontinence  of  urine  in,  88. 
increase  in  size  of  abdomen  in,  86,  94,  99, 

100,  105. 
in  one-horned  uterus,  332. 
in  double  uterus,  277. 
in  multiparse  105. 
in  primiparse,  105. 

insalivation  in,  90,  94,  99,  121. 

insanity  in,  91,  114,  701. 

insomnia  in,  122. 

inspection  of  abdomen  in,  100. 

interrogation  of  patient  in,  99. 

interruption,  premature,  of,  307. 

interstitial,  332. 

irritability  in,  113. 

iron  in  anaemia  of,  114,  122. 

journeys  in,  113. 

kiesteine  in,  94. 

knots  in  cord,  complicating,  295. 

labia  in,  86. 

lactation  in,  94. 

locomotion  in,  130. 

"longings"  in,  90,  112. 

lungs,  capacity  of,  in,  90. 

malarial  fever  in,  122,  264. 

mammas  in,  87,  88,  90,  94,  99,  105,  106. 

management  of,  112. 

mania  in,  91,  701. 

marasmus  in,  114,  118. 

marital  relations  in,  113,  116. 

melancholia  in,  91,  701. 

measles  in,  261. 

memory  in,  91,  114. 


784 


INDEX. 


Pregnancy : 
nnenses  in,  92,  93,  99. 

methods  of  physical  examination  in,  92,  99. 
milk  in,  94. 

morning  sickness  in,  90,  93,  99,  280. 
movements  of  fcetus  in,  75,  95,  96,  98-100, 

106. 
multiple,  228. 

abortion  in,  124. 

acardia  in,  229. 

conduct  of  labor  in,  236. 

development,  unequal  in,  229,  231. 

diagnosis  of,  232. 

entrance,  simultaneous,  of  both  children 
into  pelvis,  in,  234. 

foitus  papyraceus  in,  231. 

frequency  of,  228. 

hiemorrhagc  in,  236. 

hydramuiou  in,  291. 

labor  in,  232. 

locking  of  children  in,  234. 

management  of,  228,  236. 

origin  of,  228. 

placenta  m,  232. 

premature  labor  induced  in,  351. 

presentations  in.  233. 

prognosis  in,  236. 

prolapse  of  cord  in,  630. 

treat?ncnt  of,  236. 

varieties  of,  228. 

version  in,  23. 

weight  of  children  in,  231. 
nates  in,  87,  105. 

nausea  and  vomiting  in,  90,  93,  99,  116. 
navel  in,  87,  100. 
nephritis  in,  272. 
nerves  in,  91. 

nervous  irritability  in,  91,  113,  114. 
neuralgia  in,  88,  91,  114,  122. 
nipple  in,  88,  90,  94. 
nutrition  in,  89-91. 
nyctalopia  in,  91. 
odontalgia  in,  91. 
oedema  in,  88,  114,  115,  130,  268,  273,  279, 

567. 
osteophytes  in,  89. 
OS  uteri  in,  80-86,  95,  105. 
ovarian,  327,  334. 
ovaries,  position  of,  in,  79. 
ovariotomy  in,  550. 
ovulation,  suspended,  in,  93. 
pain,  abdominal,  in,  S7. 

mammary,  in,  87,  94,  99. 
palpation  of  abdomen  in,  100, 
palpitation  in,  114. 
paresis  in,  91. 
patches,  brown,  in,  91. 
pathology  of,  2t;0. 
pelvis,  contracted,  in,  465. 


Pregnancy : 
pernicious  anaemia  complicating,  114. 
pessaries  in,  116. 
phthisis  complicating,  270. 
physical  exploration  in,  99. 
physiology  of,  77. 
piles  in,  88,  115. 
placentitis  in,  289. 
plethora  of,  88. 
pleurisy  complicating,  270. 
pneumonia  complicating,  269. 
prediction  of  end  of,  105,  111. 
premature  labor,  in  anaemia  of,  115. 
prolapse  of  uterus  and  vagina  in,  282,  359. 
pruritus  in,  91,  121. 
pulse  in,  89,  118. 
puncture  in  oedema  of,  115. 
quickening  in,  95.  96,  98,  99,  101,  110. 
rectal  touch  in,  104. 
relapsing  fever  complicating,  264. 
relaxation  of  symphysis  in,  275. 
respiration  in,  90,  118. 
retardation  of  menses  in,  92. 
retroflexion  in,  116,  279,  307,  310. 

incarcerated,  280. 
retroversion  in,  116,  279,  480,  542. 
rubeola  complicating,  261. 
salivation  ia,  90,  94,  99,  118,  121. 
scarlatina  complicating,  262. 
secretions  in,  114. 
senses  in.  91. 
signs  of,  92  tt  seq. 

size  of  uterus  in,  77,  80,  100,  110,  130. 
skin,  care  of,  in,  113,  118. 
smell,  perversion  of,  in,  91. 
souffle,  funic,  in,  98. 
sounds,  use  of,  in,  101. 
speculum,  use  of,  in,  104. 
spots,  cutaneous,  in,  91. 
striae,  abdominal,  in,  87,  100,  ,105. 
striae,  mammary,  in,  87,  105. 
suppression  of  menses  in,  92,  93,  99. 
surgical  operations  during,  276. 
sympathetic  diseases  in,  93. 
syncope  in,  91,  114,  118. 
syphilis,  com[)licuting,  271. 
taste,  perversions  of,  in,  91, 
temperature  in,  118. 
thighs  in,  87,  105. 
thirst,  in,  118. 
thorax  in,  90. 
tin-ill,  uterine,  in,  100. 
thyroid  gland  in,  89. 
tooth-aciie  in,  91. 
torsion  of  cord  in,  29S,  303. 
transfusion  in,  114. 
tubal,  327,  328. 
tubo-abdominal,  338. 
tubo-ovarian,  334,  338. 


INDEX. 


785 


Pregnancy : 
tumors,  uterine,  corapliciiting,  542. 
tympanites  in,  102. 
typhoid  fever  complicating,  264  . 
typhu3  fever  complicating,  264. 
umbilicus  in,  87,  100. 
urethra  in,  105. 

urination,  frequency  of,  in,  88,  280. 
urine,  increase  of,  ni,  91. 
uterine  bruit  in,  96,  98,  103. 
uterus  in,  77,  80,  95,  101,  105,  110,  116. 
vagina  in,  85,  104,  105. 
vauinal  touch  in,  99.  103. 
varicose  veins  in,  88,  115. 
variola  complicating,  261. 
veins  in,  94. 
vertigo  in,  91,  114,  118. 
vomiting  in,  90,  93,  116,  280,  359. 
vulva  in,  86,  104,  105. 
weight  in,  90,  114. 
Precipitate  labor,  453. 

Premature  labor,  307,  349,  500  {vide  labor). 
Preparations  for  labor,  205. 
Presentations,  72,  168. 
breech,  169,  197,  382. 

anaesthesia  in,  383,  387. 

armamentarium  for,  384,  388. 

arms,  liberation  of,  in,  394. 

breech,  extraction  by,  385. 

blunt  hook  in,  388,  393. 

causes  of,  197,  481,  552. 

changes  of,  75. 

configuration  of  fretus  in,  202. 

contracted  pelvis,  influence  of,  on,  481, 
487. 

cord  in,  204,  393,  630,  635. 

definition  of,  72. 

diagnosis  of,  191,  198. 

exceptional  cases  of,  395. 

extraction  in,  382  et  seq. 

extraction  of  head  in,  396,  398. 

feet,  extraction  by,  384. 

foi'ceps  to  after-coming  head  in,  399. 

fillet  in,  388,  391. 

forceps  to  breech  in,  388. 

frequency  of,  197. 

heart-sounds  in,  103. 

in  contracted  pelvis,  481. 

in  maceration  of  foetu^,  305. 

in  twin  labors,  233. 

irregularities  in  mechanism  of,  201. 

knee,  diagnosis  of,  from  elbow,  in,  199. 

liberation  of  arms  in,  394. 

management  of  cord  in,  393. 

mechanism  of,  199,  487. 

membranes,  bag  of,  in,  198. 

mistaken  for  face,  191. 

operation  of  extraction  in,  382  et  seq. 

Prague  method  of  delivering  head  in,  398. 
50 


Presentations : 

prognosis  in,  203. 

release  of  arms  in,  394. 

rotation  of  foetus  in,  199,  395. 

traction,  direction  of,  in,  385. 

treatment  of,  204,  456. 

trunk,  delivery  of,  384. 
brow,  169,  194. 

anesthetics  in,  196. 

causes  of,  194,  481,  487,  510. 

diagnosis  of,  194. 

forceps  in,  197. 

head,  configuration  of,  in,  194. 

prognosis  in,  195. 

treatment  of,  196,  456. 
cause  of  predominating,  first,  170. 
cephalic,  169. 

diagnosis  of,  182. 
classification  of,  169. 
cranial,  diagnosis  of,  182. 
face,  109,  184. 

causes  of,  184,  481,  487. 

configuration  of  head  in,  189. 

cord,  prolapse  of,  in,  635. 

craniotomy  in,  381,  418. 

descent  of  foetus  in,  186. 

diagnosis  of,  190. 

extension  of  fetal  head  in,  186. 

external  rotation  in,  188. 

flexion  in,  188. 

forceps  in,  381. 

frequency  of,  184. 

heart-sounds  in,  103. 

in  contracted  pelvis,  481. 

influence  of  contracted  pelvis  on,  481. 

mechanism  of,  184,  186. 
abnormal,  188. 

membranes,  preservation  of,  in,  191. 

mistaken  for  breech,  191. 

perforation  in,  418. 
-    prognosis  in,  191. 

rotation  in,  187. 

treatment  of,  191,  456. 

Schatz's  method  in,  192. 
foot,  169,  202,  481. 

extraction  in,  382  et  seq. 
funis,  629. 
head,  72,  169. 

causes  of,  72. 

diagnosis  of,  182. 

heart  sounds  m,  103. 
knee,  202. 
natural,  169. 
normal,  169. 
pelvic,  169,  382. 

extraction  in,  382. 
preponderance  of  head,  72. 
shoulder,  169,  456,  481,  498,  561,  612. 

version  in,  498. 


Y86 


INDEX. 


Presentations : 

transverse,  169,  560,  564. 
embryotomy  in,  432. 
version  in,  404,  406. 
unnatural,  169,  543,  598, 
vertex,  169,  170,  179. 
configuration  of  head  in,  180. 
diagnosis  of,  182. 
trequency  of,  169. 

theories  to  account  for  preponderance  of, 
72-74. 
Pressure  of  uterus  in  labor,  140. 
Primiparffi,  signs  of  pregnancy  and  parturi- 
tion in,  105. 
Primitive  groove,  48. 
Primitive  streak,  48. 
Primitive  trace,  48. 
Primitive  vertehrse,  49. 
Primordial  ovum,  36,  38,  39. 
Prolapse : 
of  cord,  629. 
of  gravid  uterus,  282. 

causing  abortion,  282. 
of  vagina  in  pregnancy,  283,  537. 
Promontory,  false,  470. 
Promontory,  of  sacrum,  141. 
Pronucleus : 
female,  45. 
m.ale,  45. 
Pruritus  in  pregnancy,  2,  91,  121. 
Pseudo-osteomalacic  pelvis,  478,  533. 
Psoas  abscess  in  fiueii^cral  fever,  677. 
Pubes,  anatomy  of,  140,  144,  150,  155. 
Pudendum,  definition  of,  1. 

rima  of,  2. 
Puerperal  disease*,  653. 
Puerperal  eclampsia,  567  (vide  eclampsia). 
Puerperal  fever,  653. 
abscesses  in,  659-661,  674,  675,   677,   680, 

699,  700. 
alcohol  in,  697. 
analogy  between  it  and  surgical  fever,  662, 

664. 
anodynes  in,  695. 
antisepsis  in,  687,  690. 
aspiration  in,  700. 
atmospheric  causes  of,  681. 
auto-inoculation  in,  684,  690. 
bacilli,  in,  666. 
bacteria  in,  666  et  seq.^  681. 
blood-poisoning  in,  664  et  seq. 
causes  of,  495,  547,  681. 

inoculation,  683. 
cellulitis  in,  657,  658. 
chills  in,  671,  673,  676,  678-680. 
classification  of  lesions  of,  655. 
clinical  history  of,  671  et  seq. 
symptoms  of  endocolpitis  and  of  endo- 
metritis, 671. 


Puerperal  fever : 

symptoms  of  general  peritonitis,  677. 
symptoms  of  parametritis,  672. 
symptoms  of  perimetritis,  672. 
symptoms  of  septicaemia,  679. 
definition  of,  653. 

diphtheritic  patches  in,  656,  657,  679,  686. 
emboli  in,  660,  680. 
endocarditis  in,  669. 
endocolpitis  in,  656,  671. 
endometritis  in,  656,  671. 
erysipelas,  how  related  to,  686. 
frequency  of,  653. 
germs  in,  666  et  seq. 
history,  clinical,  of,  671. 
infarctions  in,  668. 
mfection,  sources  of,  in,  663. 
inflammation : 
of  genital  mucous  membrane  in,  655. 
of  peritonaeum,  uterine,  655,  659,  672,  677. 
of  subserous  pelvic  cellular  tissue  in,  655, 

659. 
of  uterine  parenchyma  in,  057. 
inoculation  of,  683. 
lesions  of,  655. 
meningitis  in,  669. 
metritis  in,  657. 

micrococci  in,  660,  666,  668,  669,  679,  681. 
microspores  in,  666,  681. 
morbid  anatomy  of,  655. 
mortality  of,  653,  686. 
nature  of,  661,  664. 
non-bacteritic  variety  of,  670. 
oedema  in,  667. 
oophoritis  in,  659,  668. 
origin,  non-local,  of,  662. 
pains  in,  672  et  seq. 
p.iramctritis  in,  657,  658,  672. 
patiiological  anatomy  of,  655. 
pelvic  cellulitis  in,  658. 
perimetritis  in,  672. 
peritonitis,  general  and  pelvic,  in,  659,  668, 

672,  677,  680. 
phlebitis  in,  660,  680. 
phlebo-thrombosis  in,  660,  680. 
pleuritis  in,  669,  6S0. 
prevention  of.  686. 
pulse  in,  672,  673,  678-680. 
pyferaia  in,  660,  680. 
relations  of,  to  zymotic  diseases,  685. 
salpingitis  in,  656. 
sapnemia  in,  661. 
scarlatina  in,  2G3,  653. 
seasons,  relations  of,  to,  685. 
septicirmia  in,  655,  660,  679,  681. 
hjmphatica,  679. 
pure,  681. 
venosa,  680. 
sewers,  affecting,  691. 


INDEX. 


78' 


Puerperal  fever : 
social  state,  relation  of,  to,  685. 
nyinptoms  of,  671. 
temperature  in,  671  et  seq. 
theory  of  milk  metastases  in,  661,  664. 
thrombi  in,  660. 
treatment  of,  686,  692. 

by  alcohol,  697. 

by  anodynes,  695. 

by  antipyretics,  696,  697. 

by  antipyrine,  697. 

by  baths,  698,  699. 

by  cauterizing  ulcers,  693.  • 

by  cold,  697. 

by  curette,  614. 

by  digitalis,  697. 

by  douche,  intra-uterine,  693,  694. 

by  douche,  vaginal,  687,  688,  692,  699. 

by  enemata,  687. 

by  laparotomy,  699. 

by  laxatives,  696. 

by  leeches,  695. 

by  opium,  695. 

by  poultices,  6  ;5. 

by  quinia,  696, 

by  salicylate  of  soda,  696. 

by  stupes,  695. 

by  veratrum  viride,  697. 

by  Warburg's  tincture,  697. 

by  wet-paek,  698. 
treatment  of  peritoneal  effusions,  699,  700. 
tympanites  in,  678,  b79. 
ulcers  in,  656,  679. 
vibrios  in,  666,  681. 
virus  of,  666. 
vomiting  in,  674,  678. 
zymotic  diseases,  relations  of,  to,  685. 
Puerperal  state,  238. 
abdomen  in,  249. 
after-pains  in,  224,  244,  252. 
air  in,  253. 
antemia  in,  645. 
anodynes  in,  252. 
anteflexion  in,  244,  249. 
antisepsis  in,  253,  688. 
appetite  in^  240. 
bandage  in,  255. 
binder  in,  224. 
bowels  in,  240. 
breasts  in,  249. 

care  of,  in,  255. 
cancer,  uterine,  in,  547. 
care  of  patient  in,  224. 
catheterisra  in,  252. 
cervix  uteri  in,  243,  249,  547. 
chill  in,  238. 

closure  of  sinuses  in,  243. 
collapse  in,  648. 
convulsions  in,  567  et  seq.,  581. 


Puerperal  state : 
cystitis  in,  252. 
death  in,  645. 

decidua,  reparation  of,  in,  241. 
diabetes  in,  240. 
diagnosis  of,  249. 
diet  in,  253. 
douche  in,  224,  2^3. 
duration  of,  255. 
eclampsia  in,  567,  581. 
embolism  in,  645. 
enemata  in,  254. 
ergot  in,  224. 
fevers  in,  653. 
general  functions  in,  240. 
hgemorrhoids  in,  254. 
hymen  in,  249. 
insanity  in,  701. 
involutio  uteri  in,  240. 
iodoform  in,  592,  688,  700. 
labia  in,  249. 
la.xatives  in,  254. 
lochia  in,  241,  245,  249,  255. 
loss  of  weiglit  in,  135,  240. 
malaria  in,  653. 
management  of,  238,  251. 
milk-fever  in,  247. 
milk,  secretion  of,  in,  246, 
nursing  in,  254. 
pad,  antiseptic  in,  225,  253. 
passing  urine  in,  252. 
perinseum  in,  224,  249. 
physiology  of,  238. 
placental  site  in,  249. 
pulse  in,  239,  248,  645. 
relation    of,    to    pathological    conditions. 

238. 
retention  of  urine  in,  240. 
scarlatina  in,  262,  653. 
secretion  of  milk  in,  246. 
separation  of  decidua  in,  242. 
shock  in,  648. 
sinuses,  closure  of,  in,  243. 
sleep  in,  251. 
syncope  in,  645. 
temperature  in,  239,  247. 
thrombosis  in,  238,  (^45. 
treatment  of,  238,  251,  687  et  neq. 
tumors,  ovarian,  in,  5.50. 
tumors,  uterine,  complicating.  542.  547. 
urine  in,  240,  252. 
uterus,  position  of,  in,  244,  249. 

involution  of,  in,  240. 
vagina  in,  105,  244,  249. 
vaginal  ulcers  in,  693. 
visits  of  physicians  in,  252. 
vulva  in,  249.  693. 
washing  of  vagina  in,  224,  253. 
weight,  loss  of,  in,  135,  240. 


Y88 


INDEX. 


Pulse : 

in  eclampsia,  568, 

in  labor,  130,  645. 

in  placenta  previa,  593. 

in  j)ost-partum  hsemoiTliage,  590. 

in  pregnancy,  89,  118. 

in  puerperal  fever,  672  et  seq. 

in  puerperal  state,  239,  248,  645. 

in  pulmonary  tlii-ombosis,  647,  648. 

in  shock,  649. 

in  uterine  inversion,  608. 

in  uterine  rupture,  615. 
Pupils  in  eclampsia,  567. 
Puncture,  in  osdenia  of  pregnancy,  115. 

followed  by  premature  labor,  115. 

in  extrau-terinc  pregnancy,  344. 
Pyaemia,  bacteria  in,  660,  668,  680. 

in  phlegmasia,  705. 

in  placenta  praivia,  599. 

in  puerperal  tever,  600,  680. 

Quadruplets,  228,  230. 
Quickening,  95,  96,  99,  101,  110. 

date  of,  95,  110. 
Quinine  : 

as  antiphlogistic,  in  puerperal  fever,  696. 

in  cephalalgia,  122. 

in  chorea,  275. 

in  mastitis,  710. 

in  phlegmasia,  706. 

in  pneumonia,  270. 

in  protracted  lirst  stage,  457,  458. 
Quintuplets,  228. 

Rachitis,   deforming    pelvis,    466,   472,   475, 

478. 
Rales,  Laryngeal,  in  delivery,  215. 
Rectal  eneraata  : 

in  anaemia,  114,  118. 

in  emesis,  118,  119. 

in  labor,  208. 
Rectal  touch,  in"  pregnancy,  104. 
Kectocele,  atresia,  vaginal,  from,  537,  623. 
Rectum,  development  of,  63. 

in  labor,  456. 

in  pregnancy,  88. 
Relapsing  fever,  complicating  pregnancy,  264. 
Repercussion  (vide  ballottement). 
Reposition  of  cord,  631. 

of  uterus,  in  retroflexion,  280,  281. 
Repositor  :' 

Braun's,  411. 

catheter  used  as,  412,  634. 

in  version,  411. 
Respiration  : 

artificial,  in  asphyxia  neonatorum^  643. 
Scliultze's  method,  643. 
Sylvester's  method,  644. 

in  pregnancy,  90,  118. 


Respiration : 
intra-uterine,  638. 
physiology  of,  635,  638. 
Restitution,  in  face  presentations,  188. 

in  vertex  presentations,  178  {vide  external 
rotation). 
Retained  placenta,  221,   225,  461,   581,   584, 

586,  592  {_vide  placenta,  retained). 
Retention  : 
in  utero^  of  dead  foetus,  302. 
of  urine — 

in  labor,  208,  537. 
in  pregnancy,  208,  2S0. 
in  puerperal  state,  240,  252. 
Retinitis,  in  nephritis,  273. 
Retraction  ring,  137,  138. 
Retraction,  uterine,  137,  454,  459,  582,  584. 
Retractores  uteri ^  15. 

Retroflexion  of  gravid  uterus,  116,  279,  307, 
310,  480,  542,  549,  592. 
abortion  in,  310. 
with  incarceration,  280,  359,  480. 
diagnosis,  280. 
treatment,  280,  316,  359. 
Retroversion  of  gravid  uterus,  116,  279,  480, 

542,  592. 
Ribs,  development  of,  64. 
Rickets,  causing  pelvic  deformity,  466,  472, 
475  {vide  rachitis.) 
Rigid  OS,  atresia  from,  540. 
Rlma pudendi^  2. 
Ringof  Bandl,  84,  137,  611. 
Kingof  Miiller,  84,  85. 
Ring,  retraction  or  contraction,  137,  138. 
Robert's  anchylosed  pelvis,  523. 
Rotation  of  fetal  head,  173. 
conditions  of,  174. 

excessive,  in  breech  presentations,  202. 
explanation  of,  175. 
external,  in  normal  labor,  177. 
in  breech  presentations,  200,  396. 
in  brow  presentations,  194. 
ill  face  presentations,  187. 
in  vertex  presentations,  173,  177. 
Rubeola  complicating  pregnancy,  261. 

with  pneumonia,  201. 
Rupture  : 
in  extra -uterine  pregnancy,  838. 
at  orifice  of  vagina,  484.  536,  622,  025. 
of  cervix,  105,  203,  539,  540,  620. 
of  genital  canal,  610. 
of  membranes,  132,  140,  208. 

to  produce  premature  labor,  353,  360. 
of  pelvic  articulations,  628. 
of  perinajum,  134,  203,  211,  224,  453,  622. 
of  uterus,  &\Q{vide  uterus,  rupture  of  the) 

in  contracted  pelvis,  481. 
of  vagina,  621. 
of  vestibule,  622. 


INDEX. 


789 


Sac: 

injections  into,  in  extra  uterine  pregnancy, 
345. 

puncture   of,  in   extra-uterine   pregnancy, 
344. 
Sacro-iliac  articulation,  145. 

rupture  of,  628. 
Sacrum,  141,  154. 

alee  of,  141. 

anatomy  of,  141. 

dimensions  of,  142. 

hiatus  sacralis  of,  142. 

lineoe  transversce  of,  141. 

male  and  female,  154. 

superficies  a  uricularis  of,  142. 
Salicylate  of  soda  in  puerperal  fever,  696. 
Salivation  in  pregnancy,  90,  94,  99,  118,  121, 

181. 
Salpingitis,  causing  tubal  pregnancy,  328. 

in  puerperal  fever,  656. 
Saprsemia  in  puerperal  fever,  661. 
Scalp-tumor,  190,  250,  369,  483,  489. 

in  brow  presentations,  194. 

in  face  presentations,  190. 
Scarlatina  : 

in  pregnancy,  262. 

jjuerperaliS;  262,  653. 
Schultze's  diagram  for  computing  pregnancy, 

109. 
Scirrhus  of  uterus,  obstructing  labor,  541,  547 

{vide  atresia,  uterine"). 
Scolio-rachitic  pelvis,  479,  521. 
Scoliotic  pelvis,  479. 
Scrotum,  development  of,  64,  65. 
Seasons,  relation  of,  to  puerperal  fever,  685. 
Sebaceous  glands  : 

of  areola,  83. 

of  foetus,  68. 

of  labia,  5. 

of  nymphfe,  5. 
Secondary  areola,  88,  94,  99. 
Section,  Csesarcan,  436   {mde  Ca?sarean  sec- 
tion). 
Secretion : 

disorders  of,  in  pregnancy,  114. 

of  milk,  246. 
Segmentation  of  ovum,  46. 
SemSn,  43. 

Senses,  special,  affections  of,  in  pregnancy,  91. 
Septicicmia : 

albuminuria  in,  680. 

bacteria  in,  666  et  seq. 

in  abortion,  313,  325. 

in  atresia,  541. 

in  extra-uterine  pregnancy,  340. 

in  ovarian  tumors,  549,  550. 

in  puerperal  fever,  655,  660,  679-681. 

in  retention  of  dead  foetus,  306,  313. 

in  transverse  presentations,  564. 


Septicaemia : 

in  tympanites  uteri,  652. 

in  uterine  cancer,  547. 

in  vaginal  thrombus,  626. 

li/mphatica,  679. 

pure,  681. 

symptoms  of,  679  et  seq. 

venosa,  680. 

vibrios  in,  666. 
Septum  : 

recto-vaginale,  9. 
laceration  of,  623. 

urethro-vagiiiale,  9. 
Serous  lochia,  245. 

iSerres fines,  in  perineal  laceration,  625. 
Ssrre-noiud,  444. 
Sex,  prediction  of,  97. 
Sexual  organs,  abnormities  of,  535 

changes  in,  in  pregnancy,  77,  105. 
Shield,  nipple,  255,  70S. 
Shock,  and  nerve  exhaustion,  492,  495,  549, 
608,  615,  620,  648. 

anodynes  Ln,  650. 

in  artificial  abortion,  353. 
Shortening,  apparent,  of  cervix  in  pregnancy, 
81. 

explanation  of,  83. 
Shoulder  presentations,  169  (vide  transverse 

presentation). 
Shoulders,  delivery  of,  178,  199,  215. 

in  breech  cases,  396. 
Signs  of  pregnancy,  92  et  seq. 

auscultatory,  96,  102,  106. 
Simpson's  forceps,  364,  379. 
Sampson's  perforator,  414. 
Sinciput,  70. 
Sinus  urogenitalis,  33. 
Sinuses,  closure  of,  in  puerperal   state,  238, 
243. 

foiTnation  of,  24. 

uterine,  24,  59.  77,  125,  238. 
Skin,  development  of,  48,  64. 

care  of,  in  pregnancy,  113,  118. 
Skull,  development  of,  64. 
Sleep  in  puerperal  state,  251. 
Sleeplessness  in  pregnancy,  122. 
Smegma  praputii,  5. 
Smell,  perversion  of,  in  pregnancy,  91. 
Smellie's  scissors,  414. 
Social  state,  relation  of,  to  pueq^eral  fever, 

685. 
Soda  in  pruritus,  121. 
Sopor  in  eclampsia,  568. 
Souffle,  funic,  98. 

uterine,  98,  103. 
Sounds,    use    of,    in    pregnancy,   101,    341, 

360. 
Speculum,  use  of,  in  craniotomy,  428. 

in  diagnosis  of  pregnancy,  104. 


790 


INDEX. 


Spermatozoa,  43. 

locomotion  of,  43. 
Sphenotribe,  431. 
Sphincter  vaginae,  9. 

Spina  bifida,  as  obstruction  to  labor,  556. 
Spinal  column,  articulation  of  fetal  head  with, 
168. 

develoi^mcnt  of,  48,  64. 
Spinous  processes  of  ilia,  distance  between, 
144,  150,  468. 

of  iscliia,  145,  153. 
Spleen : 

enlargement  of  fetal,  555. 

in  puerperal  fever,  671. 
Spondolisthctic  pelvis.  525. 
Sponges,  aseptic,  preparation  of,  360,  439. 
Sponge-tents,  use  of,  in  abortion,  353,  360. 
Spontaneous  amputation,  intra-uterine,  296. 
Spontaneous  evolution,  364  {vide  evolution). 
Spontaneous  version,  562  {olde  version). 
Spot : 

embryonic,  47,  48,  62. 

germinative,  of  ovum,  39. 
Spots,  cutaneous,  in  pregnancy,  91. 
Stage  of  labor : 

effect  of  contracted  pelvis  on  first,  483,  495, 
502. 

irregular  pains  in  first,  454. 

irregular  pains  in  second,  459. 

irregular  pains  in  third,  401. 

management  of  first,  203. 

management  of  second,  209. 

delivery  of  shoulders  in,  178,  199,  215. 
preservation  of  periiiJEum  in,  210  et  seq. 
tying  cord  in,  215,  236. 

management  of  tbird,  220. 

treatment  of  long  first,  456. 
by  anodynes  and  ana?st'netics,  466. 
by  Barnes's  dilators,  457. 
by  bougies,  457. 
by  douche,  vaginal,  457. 

treatment  of  long  second,  459. 
Staphylococci  in  puerperal  fever,  066. 
State,  the  puerperal,  238. 

abdomen  in,  249. 

after-pains  in,  224,  244,  252. 

air  in,  253. 

anodynes  in,  252. 

anteflexion  in,  244,  249. 

appetite  in,  240. 

bandage  in,  255. 

bowels  in,  240. 

breasts  in,  249. 
care  of,  255. 

catbeterism  in,  252. 

cervix,  the,  in,  243,  249. 

chill  in,  238. 

closure  of  sinuses  in,  243. 

complicated  by  scarlatina,  262. 


State,  the  puerperal : 

cystitis  in,  252. 

decidua,  reparation  of,  in,  241. 

diabetes  in,  240. 

diagnosis  of,  249. 

diet  in,  253. 

duration  of,  255. 

enemata  in,  254. 

general  functions  in,  240, 

h£emorrlioids  in,  254. 

hymen  in,  249. 

involution  in,  240. 

labia  in,  249. 

laxatives  in,  254. 

lochia  in,  241,  245,  249,  255. 

loss  of  weight  in,  135,  240. 

management  of,  238,  251. 

milk,  secretion  of,  in,  246. 

milk-fever  in,  247. 

nursing  in,  254. 

passing  urine  in,  252. 

perinaeum  in,  224,  249. 

physiology  of,  238. 

placental  site  in,  249. 

pulse  in,  239,  248. 

relations  of,  to  pathological  conditions,  238. 

reparation  of  decidua  in,  241. 

retention  of  urine  in,  240. 

scarlatina  in,  262. 

secretion  of  milk  in,  246. 

sinuses,  closure  of,  in,  243. 

sleep  in,  251. 

temperature  in,  239,  247. 

thrombosis  of  placental  vessels  in,  238. 

treatment  of,  238,  251. 

tumors,  uterine,  complicating,  542. 

urine,  passing  of,  in,  240,  252. 
retention  of,  in,  240. 

uterus,  position  of,  in,  244,  249. 
involution  of,  in,  240. 

vagina  in,  105,  244. 

visits  of  physician  in,  252. 

washing  vagina  in,  224,  253. 

weight,  loss  of,  in,  135,  240. 
Stenosis,  of  umbilical  vessels,  297. 
Stethoscope,   use  of,   in  diagnosis  of  preg- 
nancy, 102. 
Stiqmafolliculi^  39. 
Stiil-births,  635. 

Stillieidium  in  placenta  prsevia,  598. 
Stimulants  : 

in  abortion,  323. 

in  cephalalgia,  122. 

in  cerebral  anaemia,  590. 
Stockings,  elastic,  in  pregnancy,  116. 
Stomach,  development  of,  48,  50. 
Strait : 

axis  of  inferior  pelvic,  153. 

axis  of  superior  pelvic,  152. 


INDEX. 


791 


Strait : 

circumference  of  inferior,  152. 

circumference  of  superior,  152. 
forceps  at,  355. 

inferior  pelvic,  152. 

superior  pelvic,  151. 
Striee : 

abdominal,  in  pregnancy,  87,  100,  105. 

mammary,  in  pregnancy,  88,  105. 

on  nates  and  tliighs,  in  pregnancy,  87,  105. 
Stump,  treatment  of,  in  Porro's  operation,  446. 
Styptics : 

in post-partum  haemorrhage,  587,  622. 

in  puerperal  hajmorrhage,  592. 

in  puerperal  state,  693. 
Subinvolution  after  abortion,  314. 
Sugar  in  urine, /)ci«<-/'a/'<M»i,  240. 
Superfetation,  231  {vide  pregnancy,  multiple). 
Superficies  auricularis,  142. 
Surgery,  obstetric,  349. 
Surgical  operations : 

abortion  from,  276. 

during  pregnancy,  276. 

prognosis,  276. 

time  for,  277. 
Suspended  animation,  635  {vide  asphz/xia  ne- 
onatorum). 
Sutures,  70, 165. 

coronal,  70,  166, 183. 

frontal,  70,  165. 

in  Cesarean  section,  441. 

in  hydrocephalus,  552. 

in  uterine  rupture,  400,  621. 

lambda,  70,  166,  183. 

premature  ossification  of,  551. 

sagittal,  70,  183. 
Symphysiotomy.  713. 
Symphysis  pubis,  145,  154,  471. 

absence  of,  534. 

anatomy  of,  145. 

in  male  and  female,  154. 

relaxation  of,  in  pregnancy,  148,  275. 

rupture  of,  628. 
Synchondrosis,  sacro-iliuc,  145. 

motion  at,  275. 

rupture  of,  628. 
Syncope : 

in  child'>ed,  645. 

in  labor,  134,  645. 

\n post-partum  haemorrhage,  590. 

in  pregnancy,  91,  114,  118. 
Syphilis  : 

causing  abortion,  272,  308,  350. 

complicating  prognaucy,  271. 

of  placenta,  290. 

Tampon : 
in  abortion,  320,  322,  323,  324,  326,  355. 
in  hydatid  mole,  302. 


Tampon : 

in  placenta  praevia,  601,  604. 

in  uterine  prolapse,  282. 

in  vaginal  prolapse,  283. 

method  of  applying,  322,  323. 

to  produce  premature  delivery,  355. 

uterine,  in  haemorrhage,  592. 
Tannin  in  pruritus,  122. 
Tardy  labor,  453  {vide  labor,  tardy). 
Tarnier's  forceps,  377-379,  390,  400. 
Tamier's  incubator,  358. 
Taste,  perversions  of,  in  pregnancy,  91. 
Taylor's  forceps,  377,  414,  513. 
Temperature : 

in  labor,  130. 

m  post-part  um  state,  239. 

in  pregnancy,  118. 

in  puerperal  fever,  671,  672. 
Tenesmus,    vesicle,  from   retroflexed   incar- 
cerated gravid  uterus,  280. 
Tents,  in  abortion,  121,  324,  353,  360,  602. 

in  hydatid  mole,  302. 
Terminal  bulbs  of  clitoris,  3. 
Testicle : 

development  of,  65. 

fibro-cystic  degeneration  of  fetal,  555. 
Thecafolliouli  of  Graafian  follicle,  36,  38. 
Thighs,  strim  on,  in  pregnancy,  87, 105. 
Thirst  in  pregnancy,  118. 
Thomas's  operation,  447. 
Thorax  in  pregnancy,  90. 

development  of,  64. 
Thrill  in  uterine  artery  during  pregnancy, 

100. 
Thrombus : 

arterial,  645. 

cardiac,  646. 

causing  collapse  and  death  in  labor  and 
childbed,  645. 

in    placental    vessels,    physiological,    238, 
249. 

in  placental  sinuses,  288. 

in  placenta  prsevia,  599. 

in  septicaemia,  660. 

in  veins  and  lymphatics  during  phlegma- 
sia, 704. 

of  cervix,  540. 

of  labia,  5. 

of  OS,  in  labor,  540. 

of  uterine  sinuses  in  labor,  238,  583,  584. 

of  vagina,  538,  625  {vide  vagina,  thrombus 
of), 
anodynes  in,  628. 

of  vulva,  5,  526,  625  {vide  vulva,  thrombus 
of). 

treatment  of  pulmonary,  650. 

venous,  646,  660. 
Thyroid  gland,  hypertrophy  of,  in  pregnan- 
cy, 89. 


792 


INDEX. 


Torsion  of  cord,  293,  303. 
Touch,  vaginal,  in  diagnosis  of  pregnancy, 
99,  103. 

rectal,  in  pregnancy,  104. 
Trace,  primitive,  48. 

Trachelorrliapliy,  to  prevent  abortion,  318. 
Tractions,  on  forceps,  366. 

axis,  390. 

direction  of,  366,  372,  373,  377. 

time  for  making,  368,  372. 

on  cord : 
in  labor,  220,  221. 
in  retained  placenta,  463,  593. 
Trans/orateur,B.u'ben''s,  in  ccphalotomy,  431. 
Transfusions  of  blood  and  milk  m  posi-par- 
tiim  hasmorrhage,  590. 

apparatus  for,  591. 

in  anffimia  of  pregnancy,  114. 

in  cerebral  ancemia,  590. 
Transverse  diameter  of  pelvis,  151. 
Transverse  presentations,  1G9,  560. 

version  in,  404,  406. 
Transversus  perinei,  162,  164.  214. 
Trephine-perforator  in  craniotomy.  416,  419. 
Triplets,  228,  230. 
Trunk: 

delivery  of,  with  crotchet,  430. 

expulsion  of,  in  labor,  178,  554. 

extraction  of,  in  breech  cases,  384. 
Truss  in  hernia  of  uterus,  284. 
Tubal  pregnancy,  328. 
Tubes,  Fallopian,  12,  19,  30. 

ampulla  of,  19. 

anatomy  of,  19,  30. 

dilatation  of,  in  atresias,  541. 

fimbriated  extremity  of,  19. 

isthmus  of,  19. 

mucous  membrane  of,  21,  329. 

muscles  of,  20, 

non-crectility  of,  41. 

ostium  abdominale  of,  19. 

position  of,  in  pregnancy,  79. 
Tuhis  medullar  is,  50. 
Tumors : 

abdominal,  diagnosis  of,  from  preg!iancy, 
102,  549. 

fetal,  causing  dystocia,  554. 

fibroid,  of  uterus,  in  pregnancy,  102,  542. 

indicating  Cesarean  section,  438. 

intrapelvic,  causing  atresia,  533,  542. 

osseous,  deforming  pelvis,  533. 

ovarian,  548  (vide ov&ry,  tumor  of), 
in  parturition,  55f>. 
in  pregnancy,  548. 
in  puerperal  state,  550. 
obstructing  labor,  548. 

parametritic,  in  puerperal  fever,  674. 

phantom,   differentiation    of,   from    preg- 
uancv,  102. 


Tumors : 
placental,  289. 
scalp,  181,  483. 
alter  birth,  250. 
in  brow  presentations,  194. 
indicating  forceps,  369. 
in  face  presentations,  190. 
uterine : 
complicating  pregnancy,  parturition,  and 

puerperal  state,  542  et  seq. 
producincf  atresia,  541,  546. 
vaginal,  causing  atresia,  538. 
Tunica  : 
albuginea  of  ovary,  23. 
Jibrosa  of  Graafian  follicle,  36. 
propria  of  Oraafian  follicle,  36. 
Tupelo  tents  in  abortion,  121. 
Turning,  400  {vide  version). 
Twin-pregnancy,  228,  230,    233   (tide   preg- 
nancy, multiple^ 
Twins,  locking  of,  obstructing  labor,  234. 
Tympanites : 
in  Ca'sarean  section,  441. 
in  puerperal  fever,  676,  677,  679. 
mistaken  for  pregnancy,  102. 
uteri,  652. 
Typhoid  fever  complicating  pregnancy,  204. 

in  puerperal  state,  653. 
Typhus  fever  complicating  pregnancy,  264. 
in  puerperal  state,  653. 

Ulcers  in  puerperal  fever,  656,  693. 
Umbilical  cord,  60  (vide  funis). 

anomalies  of,  293. 

arteries  of,  53,  60,  61,  250. 

calcareous  degeneration  of,  298. 

care  of,  in  infants,  256. 

coiling  of,  204,  215,  296. 

cysts  in,  297. 

degenerations  of,  297. 

diseases  of,  297. 

expression  of,  630. 

formation  of.  60. 

gelatin  of,  61. 

hernias  of,  296. 

in  new-born,  250. 

knots  in,  295. 

laceration  of,  in  precij)itate  labor,  453. 

late  ligation  of,  216,  236. 

management  of,   in  breech   presentations 
393. 

marginal  insertion  of,  298. 

prolapse  of,  510,  561,  629. 

reposition  of,  631. 

shortness  of,  559. 

souffle  in,  98. 

stenosis  of  vessels  of,  297. 

structure  of  fully  developed,  61 

torsion  of,  293. 


INDEX. 


793 


Umbilical  cord : 

ante-mortem,  295. 
tying  of,  in  labor,  215,  23G. 
vein  of,  53,  60. 
vessels  of,  53,  60. 
-  Umbilical  vesicle,  50,  52,  60,  63,  64. 
Umbilical  vessels,  53,  60,  06. 

stenosis  of,  297. 
Umbilicus: 
arteries  of,  53,  60,  66. 
changes  of,  in  pregnancy,  87,  100. 
of  new-born  child,  250. 
Unavoidable  haemorrhage,  597,  60  i. 
Uraemia : 
in  eclampsia,  571,  576. 
in  retroflexion,  280. 
Urea  in  amniotic  fluid,  61. 
Ureter : 

dilatation  of  fetal,  554. 
Urethra  in  pregnancy,  105. 

in  labor,  134. 
Urinary  calculus,  obstructing  labor,  537. 
Urination,    involuntary,  in    pregnancy,    88, 
2S0. 
frequent,  in  abortion,  311. 
Urine : 
albumen  in,  during  pregnancy,  91, 118,  273, 
567. 
during  eclampsia,  567,  569  et  seq. 
during  septicemia,  680. 
atresia  from  retention  of,  537. 
casts  in,  in  eclampsia,  567. 
expulsion  involuntary,  of,  in  pregnancy,  88. 
incontinence  of,  88,  280. 
increase  of,  in  labor,  130. 

in  pregnancy,  91. 
in  hydramnion,  292. 
kiesteine  in,  94. 
of  foetus,  61,  250. 
of  infant,  250,  251. 
passing,  in  puerperal  state,  252. 
post-partum,  240. 
retention  of,  in  pregnancy,  208,  280,  368, 

537. 
retention  of,  in  puerjieral  state,  240,  252. 
suppression  of,  in  eclampsia,  573. 
Uterine  : 
atony  in  double  uterus,  278,  540. 

in  third  stage,  461. 
bruit,  in  pregnancy,  96,  98,  103. 
douche : 

in  abortion,  320,  325,  326,  354,  356. 
in  hydatid  mole,  302. 
in  post-partum  htemon-hage,  587. 
in  puerperal  fever,  683,  693,  694. 
glands,  IS. 
inertia,  454,  461. 
insufficiency,  454,  457,  401. 
pain  in  pregnancy,  127,  131, 


Uterine : 
paralysis,  454. 
souffle,  98,  103. 

tumors  obstructing  labor,  542. 
vessels,  air  in,  647. 
Uterus : 
abnormal  conditions  of,  277. 
abnormities  of,  33,  260,  277. 
action  of,  in  labor,  135. 
action  of  pains  on  walls  of,  128. 
amputation  of,  in  rupture,  618. 
anatomy  of,  10. 
anteversion  and  anteflexion  of,  80,  116,  278. 

causing  abortion,  310. 

in  puerperal  state.  244,  249. 
arteries  of,  23,  24,  59,  77,  79,  103. 

in  pregnancy,  77,  79,  95,  101,  105. 

internal  spermatic,  25. 

tiirill  in,  during  pregnancy,  100. 

uterlna  hypogastrica ,  23. 
atresia  of,  539  (vide  atresia,  uterine), 
atrophy  of  mucous  membrane   of,  causing 

abortion,  309. 
Mcornis,  34. 
body  of,  12,  18. 

bruit  in,  during  pregnancy,  96,  98,  103. 
cancer  of  neck  of,  546. 

treatment  of,  547. 
catheterization  of,  to  produce  abortion,  352, 

580. 
causes  of  enlargement  of,  78. 
cavity  of  body  of,  13. 
center,  motor,  for  contractions  of,  126. 
cervix  or  neck  of,  12. 
changes  in,  in  pregnancy,  77-86,  105,  116, 

131,  1.37. 
compression  of,  in  labor,  220. 
contractions  of,  in  labor,  127,  311,  454,  582. 
contractions  of.  in  pregnancy,  101, 124, 127. 

effect  of  chloroform  on,  227. 

method  of  causing,  in  post-partum  ha'm- 
orrhage,  585. 
cordiformk,  34. 
corpus  of,  12. 
cornua  of,  33. 

curetting  of,  in  puerperal  haemorrhage,  592. 
development  of,  30. 
didelphi/s,  34. 
dilatation  of  fetal,  555. 
dimensions  of,  post-partum,  241,  244,  249. 
displacements  of  gravid,  80,  110,   278,310, 
480. 

double.  34,  277,  540. 
causing  abortion,  278. 
drainage  of,  618. 
duplex,  341,  277,  540. 
erectility  (theoretical)  of,  26. 
evacuation  of,  in  abortion,  320,  321. 
fluctuation  in  gravid,  100. 


i94 


INDEX. 


Uterus : 
fimdus  of,  12,  130. 
gangrene  of,  in  retroflexion,  280. 
glands  of,  18. 
gravid,  TT,  95,  101,  105,  lOG. 

anteversion  and  anteflexion  of,  80,  IIC, 
278. 

retroflexion  of,  116,  279,  310,.  480. 

retroversion  of,  116,  279,  480. 
with  incarceration,  280,  859,  480. 
growth,  early  lateral,  of,  79,  123. 
hernia  of  gravid,  283. 
liour-glass  contraction  of,  224. 
hypero3mia  ot  gravid,  310. 
hypertrophy  of  mucous  membrane  of,  310. 
incarceration  of  i-etroflexed,  2^0,  359. 
injections  between,  and  ovum,  to  produce 

abortion,  352. 
injections  into,  mpost-pat-tiim  hemorrhage, 

587.  589. 
in  puerperal  peritonitis,  678. 
in  puerperal  state,  241,  244,  249. 
inversion  of,  453,  560,  594,  607. 
involution  of,  240. 
irritability  of,  in  gestation.  127. 
laceration  of  cervix  of,  105,  203,  453,  539, 

620. 
ligaments  of,  15,  16. 

contraction  of,  in  labor,  128. 
lymphatics  of,  28,  77. 
measurements  of  gravid,  78. 
motor  center  of,  126. 

mucous  membrane  of,  18-20,   77,  81,  242, 
309. 

atrophy  of,  309. 

crypts  in,  55,  242. 

hypertrophy  of,  310. 
muscles  of,  16. 

in  pregnancy,  77-86,  124. 
myomata  of,  542  et  seg. 

treatment  of,  543. 
nerves  of,  27,  77,  126,  311. 
neck  of,  12. 
one-horned,    pregnancy    in     rudimentary 

cornu  of,  3."2. 
OS  internum  of,  13. 
paralysis  of,  456. 

perforation  of,  from  pressure,  C20. 
peritonaeum  of,  16,  79. 
Porro's  operation  for  removal  of,  442. 
position  of,  in  puerperal  state,  244. 

in  pregnancy,  75. 

post-partum,  244. 
prolapse  of,  complicating   pregnancy,  282, 

359. 
reflex   action  of,  causing  vertex  presenta- 
tions, 75,  126. 
removal  of,  by  Porro's  operation,  442. 
retention  in,  of  dead  fcctus,  302. 


Uterus : 
retraction  of,  137,  454,  459,  582. 

methods  to  cause,  589. 
retroflexion    and    retroversion   of   gravid. 
116,  279,  359,  480. 

treatment  of,  280,  316,  359. 
rupture    of,   353,  387,  400,  410,  412,    443, 
481,  484,  492,  540,  542,  553,  610,  OiO. 

clinical  history  of,  615. 

diagnosis  of,  615. 

etiology  of,  611. 

pathology  of,  614. 

treatment  of,  616. 
semi-parfiti/s,  34. 
septus  Mlocularis,  34. 
shape  of  gravid,  80,  100,  123. 
sinking  of  gravid,  80,  90,  130. 
sinuses  of,  24,  59,  77, 125,  238. 
size  of,  in  liydatidiform  mole,  301. 

in  pregnancy,  77,  80,  100,  110. 

posf-pa7-tum,  242,  244,  249. 
softening  of,  in  pre.unancy,  194. 
thrombi  in  sinuses  of,  583,  599. 
tumors  of,  complicating  prciinaucy,  542. 

causing  hemorrhage,  584. 
tympanites  of,  652. 
unicornis,  34. 
veins  of,  24,  59,  77. 

in  pregnancy,  77,  124. 

thrombi  in,  646,  660. 
vessels  of,  and  of  its  appendages, 23, 124, 242. 
weight  of  gravid,  78,  124. 

in  puerperal  state,  241. 
weight  of  virgin,  78. 

Vagina : 

absence  of,  536. 
anatomy  of,  8,  162. 
arteries  of,  10. 
atresia  of,  536. 

accidental,  536. 

congenital,  536. 

from  calculi,  537. 

from  cystic  degeneration,  538. 

from  cystocelc,  537.  * 

from  double  vagina,  538. 

from  cchinococci,  538. 

from  neoplasmata,  538. 

from  prolapse  of  vagina,  537. 

from  rectocele,  537. 

from  retention  of  urine,  537. 

from  thrombus,  538,  626. 

from  vaginal  hernia,  537. 

from  vaginismus,  538. 

from  vesical  calculi,  537. 
bulbs  of  vestibule  of,  5,  102. 
changes  of,  in  pregnancy,  85,  105,  131. 
changes  of,  in  puerperal  state,  244,  249. 
color  of,  in  pregnancy,  104. 


INDEX. 


795 


^'agifta : 
columns  of,  9. 
constrictor  of,  162. 
cristce  of,  10,  105. 
cystic  degeneration  of,  538. 
clevelopineut  of,  30. 
double,  277,  538. 
douche  in : 

in  abortion,  320,  322. 

in  pregnancy,  113,  122. 

ill  puerperal  hEemorrbage,  592. 

in  puerperal  state,  224,  253,  693. 

in  long  first  stage  of  labor,  457. 

in  retained  placenta,  594. 

to  cause  abortion,  354,  35(5. 

to    prevent    puerperal    fever,   687,    092, 
699. 
erectility,  theoretical,  of,  9. 
examination    by,   in    pregnane}-,  99,   103, 

206. 
fornix,  of,  9. 
glands  of,  10,  162. 
influence  of,  on  labor,  129. 
in  pregnancy,  85,  104,  105,  131. 
in  puerperal  state,  244,  249. 
laceration  of,  453,  484,  543,  621. 
laceration  of  orifice  of,  484,  536,  622,  625. 
muscles  of,  9,  162. 

in  pregnancy,  85. 
ojdema  of,  in  pregnancy,  114. 
orificiwm  of,  6,  7. 
papillfE  of,  10,  86,  105. 

hypertrophy  of,  86,  105. 
mucous  membrane  of,  10,  85. 

in  pregnancy,  85,  104. 
neoplasms  of,  538. 
non-erectility  of,  9. 

orifice  of,  6,  7. 
prolapse  of,  in  pregnancy,  283,  537. 

from  laceration,  623. 
sphincter  of,  9. 

stenosis  of,  indicating  forceps,  368. 
structure  of  walls  of,  9. 
tampon  applied  to : 

in  aBortiou,  320-324,  326,  355. 

in  hydatidiform  moie,  302. 

in  placenta  pra3via,  601. 

to  produce  abortion,  355. 
thrombus  of,  538,  625. 

anodynes  in,  628. 

atresia  from,  538,  625. 

Barnes's  dilator  in,  627. 

diagnosis  of,  626. 

etiology  of,  626. 

prognosis  ol",  626. 

symptoms  of,  625. 

treatment  of,  627. 
ulcers  of,  536,  693. 
veins  of,  10. 


Vagina : 

in  pregnancy,  85,  626. 
walls  of,  their  structure,  9. 
Vaginal  columns,  9. 

Vaginal  douche,  113  {vide  douche,  vaginal). 
Vaginal  growths,  atresia  from,  538. 
Vaginal  touch,  in  the  diagnosis  of  pregnancy, 

99,  103. 
Vaginismus,  atresia  from,  538. 
Vagitus  nterinus,  642,  652. 
Valve : 
Eustachian,  66,  68,  637. 
of  foramen  ovale,  66,  08. 
Varicose  veins  in  pregnancy,  88,  115. 
Variola  in  pregnancy,  261. 
Vaseline  in  pruritus,  121. 
Vectis,  362. 
Veins : 
cervical,  26. 

hEemorrhoidal,  in  pregnancy,  115. 
inflammation  of,  in  puerpei-al  fever,  660. 
internal  spermatic,  26. 
mammary,  in  pregnancy,  87,  94,  99. 
ovarian,  26. 
pelvic,  158. 
thrombi  in,  646,  660. 
umbilical,  53,  60,  66,  250. 
uterine,  24,  59,  77,  046,  60O. 
utero-ovarian,  25,  26. 
vaginal,  10. 

varicose,  in  pregnancy,  88.  115,  626. 
elastic  stockings  in,  116. 
ergotine  in,  116. 

in  vaginal  and  vulvar  thrombus,  626. 
Venesection  in  eclampsia,  579,  581. 

in  pneumonia,  270. 
Ventilation  in  hospitals,  682,  689. 
Veratrum  viride  : 

in  eclampsia,  579,  581. 
in  puerperal  fever,  697. 
Vernix  caseosa,  65,  68. 

removal  of,  256. 
Version,  400. 
after  complete  retraction  of  uterus,  409. 
after  craniotomy,  430. 
after  embryotomy,  432. 
after  rupture  of  membranes,  405. 
anaesthetics  in,  404,  406,  410. 
cephalic,  401. 

Braxton  Ilicks's  method,  403,  404. 
Buseh's  method,  402. 
combined  methods,  401,  404. 
D'Outrepont's  method,  403. 
external  method,  401. 
Hohl's  method,  403. 
Wigand's  method,  401. 
"Wright's  method,  403. 
combined,  401,  404. 
decapitatii:>«>  in,  413. 


796 


INDEX. 


Version : 
external,  401. 

hand  employed  in,  -106,  407. 
in  accidental  hsemorrhasre,  GOG. 
in  breech  and  foot  cases,  204,  38G. 
in  brow  presentations,  196. 
in  contracted  pelves,  498,  499,  503  et  seq. 
in  craniotomy,  430. 
in  death  of  mother,  651. 
in  face  presentations,  3S1. 
in  head  presentations,  404, 
in  heart  diseases,  268. 
in  lateral  positions,  407. 
in  multiple  pregnancy,  23G. 
in  placenta  prsevia,  G02,  603. 
iu  prolapse  of  funis,  631,  633,  034. 
in  rupture  of  uterus,  61G. 
in  Thomas's  operation,  450. 
internal,  401,  405. 

in  transverse  presentations,  404,  406. 
in  uterine  myoma,  645. 
neglected,  408. 
podalic,  401,  404. 
bipolar  method,  404. 
combined  method,  404. 
indications  for,  404. 
repositors,  use  of,  in,  411. 
spontaneous,  562. 
etiology,  502. 

mecbanism  of  complete,  563. 
mechanism  of  partud,  503. 
prognosis  in,  564. 
use  of  catheter  as  repositor  in,  412. 
use  of  tillet  in,  411. 
use  of  repositor,  Braun's,  in,  411. 
Vertebrae,  primitive,  49. 

Verte.x  presentation,  169  et  seq  (iride  presen- 
tation, vertex). 
Vertigo  in  pregnancy,  114,  118. 

in  eclampsia,  507. 
Vesicle : 
blastodermic,  47,  50. 
germinative.  of  ovum,  39,  45. 

disappearance  of,  45. 
umbilical,  50,  51,  52,  60,  63,  64. 
Vesicles,  cerebral,  63. 
development  of,  63. 
Vessels : 
cervical,  26,  27. 
collapse  and  death  from  entrance  of  air  into 

uterine,  355.  647. 
umhilical  stenosis  of,  297. 
uterine,  23,  79. 
entrance  of  air  into,  355,  647. 
Vestibnlum,  4. 
bvlbi  of,  4,  622. 
glandidce  of,  5,  6. 
laceration  of,  622. 
Vibriones  in  septic£emia,  COG,  6§J. 


Viburnum  prunifolium  in  abortion,  317,  318. 

in  salivation,  121. 
Villi,  chorial,  51-53,  56,  64,  289,  329. 
abortion  from  degeneration  of,  SOS. 
of  cat,  56. 
of  mare,  55. 
placental,  56. 
Vinegar  in  posi-paHtini  hDcmorrhage,  588. 
Virus  of  puerperal  fever,  006. 
Visceral  arches,  63. 

Visits  of  physician  in  puerperal  state,  252. 
Vitelline  membrane  of  ovum,  38. 
Vitellus,  or  yolk,  of  ovum,  39. 
appearance  of  nucleus  of,  45. 
segmentation  of,  45. 
Volsella  forceps  in  embryotomy,  432. 
Vomiting: 
causing  haemorrhage,  585. 
in  incarcerated  retrctiexed  gravid  uterus, 

280,  359. 
induction  of  abortion  for,  117,  351,  359. 
in  eclampsia,  567. 
in  hydramnion,  292. 
in  pregnancy,  90,  93.  99,  116,  117,  351. 
in  puerperal  fever,  674,  078. 
in  rupture  of  uterus,  615. 
in  shock,  649. 
Vulva,  2. 
atresia  of,  535. 
cancer  of,  536. 
changes  in,  during  pregnancy,  86, 104,  105, 

115. 
color  of,  in  pregnancy,  104. 
connicens.  2. 
erosions  of,  622. 
fourcliette  of,  4. 
frenulum  of,  4. 
hfematoma  of,  536. 
Mans,  2. 

laceration  of,  536,  622. 
glands  of,  5,  162. 

in  pregnancy,  E6. 
oedema  of  : 

in  labor,  130,  368,  620. 

in  pregnancy,  86,  104,  105,  115,  131,  134, 

280,  536. 
in  puerperal  state,  249. 
polypus  of,  536. 
pruritus  of,  122. 

stenosis  of,  indicating  forceps,  368. 
thrombus  of,  5,  536,  625. 
diagnosis  of,  626. 
etiology  of,  626. 
prognosis,  of,  626. 
symptoms  of,  f  25. 
treatment  of,  627. 
ulcers  of,  in  puerperal  fever,  656,  693. 
varicose  veins  of,  in  pregnancy,  88,  104, 
115,  626. 


INDEX. 


T97 


Vulvo- vaginal: 
follicles,  5,  6. 
glands,  5,  6. 

Wallace's  forceps,  365. 

Walls  of    abdomen    obscuring    pregnancy, 

102. 
Waters,  false,  562. 
Water,  hot,  in  lia?morrhage,  587. 
Weight : 

gain  of,  during  pregnancy,  90. 

less  of,  in  pregnancy,  114. 

loss  of,  in  puerperal  state,  135,  240. 

of  f(jetus  at  term,  69,  251. 

of  foetus  in  multiple  pregnancy,  231. 


Weight : 

of  gravid  uterus,  78. 

of  virgin  uterus,  78. 
Wet-nurse,  selection  of,  256. 
Wet-pack,  use  of,  in  puerperal  fever,  698. 
Wharton's  gelatin,  61. 
Whisky  in  yost-'partum  h.Tinorrhage,  5£0. 
White's  forceps,  365. 
Wolffian  bodies,  29. 

Yolk  of  ovum,  39. 

Zona  pcllucida  of  ovum,  38,  46. 
Zymotic  diseases,  their  relation  to  puerperal 
fever,  685. 


THE   END. 


I 


4 


THE  DISEASES  OF 
IMkMY  km  CHILDHOOD. 

J^or  the  Use  of  Students  and  Practitioners  of  Medicine. 
By  L.  EMMETT  HOLT,  A.  M.,  M.  D., 

Profes&or  of  DUeases  of  Children  in   the  JVeiv   York  Polyclinic ;   Attending  Physician  to 

the  Babies'  Hospital  and  to  the  JS'ursery  and    Child's  Hospital^  Is-ew   York; 

Consulting  Physician  to  the  New  York  Infant  Asylum^  and  to  the 

Huspital  for  Puptured  and  Crippled. 

With  7  full  page  Colored  Plates  and  203  Illustrations.     Cloth,  $6.00  , 
sheep,  $7.00  ;  half  morocco,  $7.50. 

soi.r>  o:NrLY  by  sxjbscripxion'. 


Azaerican  Medico-Surgical  Bulletin: 

"  This  work  is  in  every  sense  of  the  word  a  new  book  ;  for,  while  the  best  work  of  other 
authors  in  this  and  other  countries  has  been  di'awn  upon,  especially  that  in  tlie  form  of 
monoi^raphs  and  in  the  flies  of  paediatric  literature,  the  majority  is  derived  trom  the  author's 
own  clinical  observations.  Obsolete  dicta  handed  down  from  te.xt -book  to  te.\t-book  are 
here  conspicuously  absent,  and  nothing  has  been  accepted  which  has  not  been  carefully 
tested.  ...  It  is  not  veuturinar  too  much,  after  a  careful  perusal  of  these  pages,  to  predict 
for  tliis  volume  a  pre-eminent  and  lasting  position  among  the  treatises  upon  this  subject. 
We  heartily  recommend  that  it  iiud  a  place  not  only  in  the  library  of  every  physician,  but 
wide  open  at  the  elbow  of  every  man  who  desires  to  deal  intelligently  with  the  problems 
which  confront  liim  in  the  treatment  of  infants  and  children  intrusted  to  his  care." 

ITashviUe  Journal  of  Medicine  : 

"  This  mainiflecnt  work  is  one  of  the  most  valuable  recent  contributions  to  medical  liter- 
ature. It  will  rapidly  win  its  way  to  a  front  rank  with  other  standard  works  upon  kindred 
subjects.     It  is  as  nearly  complete  as  a  treatise  upon  tliis  subject  can  be." 

Virginia  Medical  Semi-Monthly  : 

"  When  one  recalls  the  teachings  of  a  decade  or  two  ago  and  compares  the  inculcations 
of  to-day,  he  can  scarcely  help  recognizing  that  '  old  thing's  have  passed  away,  and  all 
things  have  become  new.'  The  volume  befoi-e  us  is  practically  the  record  of  information 
obtained  by  the  author  from  eleven  years  of  special  study  and  practice,  so  that  nearly  every 
subject  is  presented  from  the  standpoint  of  personal  observation  and  experience.  The 
information  given  is  therefore  reliable,  for  Y)r.  Holt  is  a  close  observer  and  a  careful  student 
of  his  ripe  experience.  ...  In  short,  this  book  appears  to  us  to  be  the  best  all-round,  up-to- 
date  book  for  practitioners  and  students  of  children's  diseases  that  we  know  of." 

Medical  Progress : 

"  The  work  before  us  is  one  which  reflects  great  credit  upon  the  distinguished  author. 
r>r.  Ilolt  has  long  been  known  as  a  most  industrious  and  painstaking  investigator,  and  in 
this  volume  he  sustains  that  reputation.  The  work,  we  may  say  in  a  sentence,  is  fully  up 
to  the  requirements  of  the  times,  and  there  is  no  advance  known  to  piediatrics  which  has 
not  been  fully  dealt  with  according  to  its  merits." 


D.    APPLETON   AND    COMPANY,    NEW   YORK. 


TPIE  MENOPAUSE. 


A  CONSIDERATION  OP  THE  PHENOMENA  WHICH  OCCUR  TO 

WOMEN  AT  THE   CLOSE   OF  THE   CHILDBEARING 

PERIOD,  WITH    INCIDENTAL   ALLUSIONS 

TO   THEIR   RELATIONSHIP   TO 

MENSTRUATION. 

^Iso  a  Particular  Consideration  of  the  Premature  {especially  the 
Artificial)  Menopause. 

By  ANDREW   F.   CURRIER,  A.  B.,  M.  D., 

NEW  YOKK  CITY. 


12mo,  28Jf  pages.       Cloth,  $2.00. 


"  Such  a  universally  important  topic  as  the  menopause  deserves  the  extended 
consideration  given  it  in  this  volume.  The  author  takes  the  ground  that  this 
period  of  woman's  life  is  not  so  fraught  with  danger  as  taught  in  previous  works  on 
the  subject.  He  also  corrects  the  prevalent  idea  of  an  intimate  relationship  be- 
tween cancer  and  the  menopause.  Artificial  menopause  is  carefully  considered.  It 
is  a  most  valuable  book,  and  should  be  in  the  hands  of  every  physician." — Nash- 
ville Journal  of  Medicine  and  Surgery. 

"  This  is  a  remarkably  interesting  treatise  upon  a  subject  but  scantily  dealt  with 
by  writers  upon  general  medicine.  The  author  has  taken  great  pains  to  make  a 
thorough  study  of  the  topic,  and  his  conclusions  are  arrived  at  by  logical  methods 
of  reasoning.  He  shows,  what  many  medical  men  have  long  suspected,  that  the 
climacteric  is  not  of  itself  a  cause  of  disease,  and  that  normally  it  passes  by  with- 
out observable  effect." — Northwestern  Lancet. 

"  This  is  a  sensible,  honest  book.  Through  it  the  author  has  made  a  contribu- 
tion to  medical  literature  of  more  than  ordinary  value.  This  conclusion  is  reached 
not  because  of  the  great  intrinsic  value  of  the  facts  adduced,  but  because  ^very 
page  bears  the  earnuii'ks  of  conscientious  research.  If  Dr.  Currier  has  not  given 
us  more  scientific  knowledge  than  we  possessed  before,  it  is,  we  are  convinced,  be- 
cause such  knowledge  is  unavailable." — Medical  News. 

"  The  monograph  before  us  is  certainly  one  which  has  been  long  demanded  by 
the  medical  profession.  .  .  .  Taken  altogether  this  is  a  most  excellent  little  book, 
which  we  can  heartily  recommend  to  all  physicians  as  the  latest  and  most  advanced 
and  consequently  the  best  on  the  subject." — St.  Louis  Medical  and  Surgical 
Journal. 


D.  APPLETON  AND   COMPANY,  NEW  YORK. 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DU^^^pjthe-last.date  stamped  below. 


m. 


N0V16JZ0 

NOV  18  19^0 


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lil^ 


T*  DtC    2 197C 


B/OMEOL«t 


IB. 

JUL28RECT) 
WOMED  SEP  26  '84 


SEP 


BldlEl?^^ 


J  UN  0  9  ]988 
BIOMED 


JU[<B«P«t^3-tB 
JUN061988 

REC'O 

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MmU  1SS8 
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